What to do when the parathyroid gland is not found during a transcervical exploration?

The most frequent cause of suboptimal results in a parathyroid adenoma resection is an ectopic location, mainly in the anterior mediastinum. These cases may not always be resected through a traditional cervical access. We present 2 cases of primary hyperparathyroidism who underwent an unsuccessful bilateral cervical exploration due to parathyroid tissue located inside the thymic gland. A video-assisted thoracoscopic surgery thymectomy with intraoperative determination of blood parathormone levels was performed. A 50% reduction of intraoperatory parathyroid hormone blood from the highest basal level at 5 and 10 min after resection was obtained. Final pathological results showed an intra-thymic parathyroid adenoma in the first patient and an intra-thymic focus of parathyroid hyperplasia in the second patient. In conclusion, video-assisted thoracoscopic surgery thymectomy could be the optimal approach to resect ectopic parathyroid adenomas located in the anterior mediastinum.

Tratamiento quirúrgico de la metástasis adrenal única en pacientes con cáncer de pulmón / Surgical treatment of solitary adrenal metastases in patients with lung cancer

Fundamento y objetivo: El cáncer de pulmón (CP) puede afectar a la glándula adrenal como metástasis única. El objetivo de este estudio es describir la experiencia en nuestro centro sobre pacientes intervenidos quirúrgicamente de metástasis suprarrenal de CP en los últimos 11 años. Pacientes y método: Se ha realizado un estudio retrospectivo descriptivo de los pacientes intervenidos quirúrgicamente de adrenalectomía por metástasis de CP. Resultados: Se incluyen 7 pacientes con una mediana de edad de 64 años. A 5 de ellos se les realizó una lobectomía y a 2 una neumonectomía con tratamiento adyuvante según protocolo. La metástasis suprarrenal única se presentó de forma sincrónica en 3 pacientes y metacrónica en 4, entre 10 y 39 meses (mediana de 25 meses). Dos pacientes siguen vivos y con buena calidad de vida. La supervivencia media de los pacientes fue de 41 meses (intervalo de confianza del 95% [IC 95%] 7-74), y la supervivencia mediana, de 20 meses (IC 95% 7-32). Conclusiones: Se puede afirmar que la ciru ía de la metástasis adrenal por CP aumenta la esperanza de vida en determinados pacientes según la bibliografía disponible (AU)

Background and objective: Lung cancer (LC) can metastasize the adrenal gland. The objective of this study is to describe our experience in patients undergoing surgery for solitary adrenal metastasis of lung cancer in the past 11 years. Patients and methods: It is a retrospective study of patients who underwent the surgical resection of the lung primary tumor and the adrenal metastases. Results: We included 7 patients with a median age of 64 years. Five patients underwent lobectomy, and 2, pneumonectomy with adjuvant therapy according to protocol. The single adrenal metastasis appeared synchronously in 3 patients and metachronously in 4, between 10 and 39 months (median 25 months). Two patients are alive and with good quality of life. The mean survival of patients was 41 months (95% confidence interval [95% CI] 7-74) and median survival was 20 months (95% CI 7-32). Conclusions: We conclude that surgery adrenal metastases from lung cancer increases life expectancy in selected patients according to the available literatura (AU)

[Surgical treatment of solitary adrenal metastases in patients with lung cancer]. / Tratamiento quirúrgico de la metástasis adrenal única en pacientes con cáncer de pulmón.

BACKGROUND AND OBJECTIVE: Lung cancer (LC) can metastasize the adrenal gland. The objective of this study is to describe our experience in patients undergoing surgery for solitary adrenal metastasis of lung cancer in the past 11 years. PATIENTS AND METHODS: It is a retrospective study of patients who underwent the surgical resection of the lung primary tumor and the adrenal metastases. RESULTS: We included 7 patients with a median age of 64 years. Five patients underwent lobectomy, and 2, pneumonectomy with adjuvant therapy according to protocol. The single adrenal metastasis appeared synchronously in 3 patients and metachronously in 4, between 10 and 39 months (median 25 months). Two patients are alive and with good quality of life. The mean survival of patients was 41 months (95% confidence interval [95% CI] 7-74) and median survival was 20 months (95% CI 7-32). CONCLUSIONS: We conclude that surgery adrenal metastases from lung cancer increases life expectancy in selected patients according to the available literature.

Determining the appropriate sleeve lobectomy versus pneumonectomy ratio in central non-small cell lung cancer patients: an audit of an aggressive policy of pneumonectomy avoidance.

OBJECTIVE: To study the outcomes of broncho ± angioplastic sleeve lobectomy (SL) versus pneumonectomy (PN), and the PN:SL ratio after an aggressive policy of parenchyma-sparing surgery to improve postoperative complications rate and long-term quality of life (QoL). METHODS: A prospective study was conducted in 490 patients with non-small cell lung cancer between 2005 and 2009. All patients not suitable for standard lobectomy were scheduled for SL, if possible, or for PN; eight patients with functional impairment were directly scheduled for SL. RESULTS: Of 76 procedures, 21 (4%) were PN and 55 (11%) SL (29 bronchoplastic, seven bronchovascular, seven angioplastic; 11 extended to more than one lobe). There were no surgical, oncological or physiological preoperative differences between the groups. The 5-year PN:SL ratio was 1:2.6 (2005: 1:2.1; 2006: 1:2.6; 2007: 1:3.6; 2008: 1:3; 2009: 1:3.5). SL and PN mortality were 2 (3.6%) and 1 (5%), respectively. Postoperative complications occurred in 18 (32%) SL and 7 (33%) PN patients. pN1 (p = 0.04), vascular reconstruction and upper-left SL were risk factors for postoperative complications of SL (p = 0.03) but were not detected as a mortality risk. Overall 5-year survival was 61% for SL and 31% for PN. Survival at 5 years was significantly higher for SL (p = 0.03, Kaplan-Meier). Age <70 years and SL were positive factors for long-term survival. In multivariate modelling, both remained positive factors. Surviving PN patients experienced significantly greater loss of respiratory function and lower QoL than those who avoided this surgery (preoperative score, PN vs SL: 52 vs 51; 3 months, 41 vs 43; and 6 months, 42 vs 51, p = 0.04). The adjuvant treatment complement was higher in SL at 34 (62%) than at PN 10 (47%). The side effects of this treatment were more frequent in patients with more extirpated parenchyma (p = 0.04). CONCLUSIONS: Parenchyma-sparing procedures can reduce the PN rate to less than 10%. A PN:SL index lower than 1:1.5 as a quality standard in a specialised thoracic unit should encourage the use of broncho-angioplastic procedures and improve patient outcomes. Long-term survival, QoL, postoperative lung function test and tolerance of adjuvant therapies are significantly better after SL than PN intervention.

A medical alternative to the treatment of compensatory sweating.

Compensatory sweating after sympathectomy does not have a satisfactory, free-of-secondary-effects treatment. Glycopyrrolate has been successfully used to treat other types of hyperhidrosis. Compensatory sweating after sympathectomy could respond to the topical application of glycopyrrolate. Ten patients were selected with compensatory sweating after sympathectomy. One milliliter of a 2% water solution of topical glycopyrrolate was applied once a day over the affected area and massaged for 30 seconds. Treatment was maintained for 6 weeks. The results were rated using a scale from 1 to 10 of satisfaction at the end of the study. Eight of the 10 treated patients dramatically improved with the topical application of glycopyrrolate. Two patients quit the treatment due to secondary effects (accommodative failure and dry mouth). The results of the study demonstrated that local application of glycopyrrolate might be the treatment of choice for compensatory hyperhidrosis.