Hypercalcemic Crisis Secondary to a Superior Mediastinal Parathyroid Adenoma: A Case Report.

Hypercalcemic crisis is a rare endocrine emergency that occurs in a small percentage of patients with primary hyperparathyroidism. Although modern diagnostic capabilities allow timely diagnosis and intervention, hypercalcemic crisis still has a high potential for morbidity and mortality. We report an adult patient with a history of kidney stones who presented with heart palpitations, shortness of breath, fatigue, nausea, and 20-pound weight loss over 2 months. Workup revealed hypercalcemia, elevated parathyroid hormone (PTH), and a mediastinal mass on computed tomography angiography. This patient's hypercalcemic crisis was treated with intravenous hydration using normal saline, zoledronate, and furosemide. After medical optimization, the patient underwent definitive treatment with surgical parathyroidectomy via a transcervical approach. At operation, a large parathyroid adenoma was removed from a posterior-superior mediastinal location dorsal to the recurrent laryngeal nerve with subsequent normalization of calcium and PTH. We discuss the timing of parathyroidectomy in cases of hypercalcemic crisis and the surgical approach to ectopic parathyroid glands in the mediastinum.

Mucoepidermoid carcinoma of the parotid gland: the Mayo clinic experience.

OBJECTIVE: To determine clinical and histopathologic features of mucoepidermoid carcinoma of the parotid gland, specifically, the relation of tumor stage and grade and treatment type with clinical outcome. DESIGN: Retrospective clinical and histopathologic review. SETTING: Tertiary care medical center. PATIENTS: From 1940 to 1994, 128 patients were treated at our institution for parotid mucoepidermoid carcinoma. Eighty-nine of these patients had their first treatment at our institution; these cases were chosen for retrospective clinical and histopathologic review. INTERVENTION: A head and neck pathologist independently reviewed the pathology specimens. MAIN OUTCOME MEASURES: Age, symptoms, stage, treatment type, tumor grade, pathological features, disease progression, and survival. RESULTS: Results of clinical staging were: T1 in 56 patients, T2 in 13, T3 in 1, T4 in 15, N0 in 85, N1 in 2, and N2 in 2. No patient had N3 or M1 disease. All patients underwent parotidectomy with or without neck dissection. Seven patients received postoperative radiotherapy. Tumor grade was low in 43 patients (48%), intermediate in 40 (45%), and high in 6 (7%). Only 5 patients had disease progression (local recurrence in 4, regional recurrence in 4, and distant recurrence in 2). At latest follow-up (mean follow-up, 14.7 years), 64 patients were alive without disease, 1 was alive with disease, 2 had died of mucoepidermoid carcinoma, and 22 had died of other causes. The Kaplan-Meier estimated cancer-specific survival rates at 5, 15, and 25 years were 98.8%, 97.4%, and 97.4%, respectively. CONCLUSIONS: In our study, tumor grade and stage appeared to be less important than previously described. With adequate parotidectomy and appropriate neck dissection, patients with mucoepidermoid carcinoma of the parotid gland appear to do well, with few recurrences.

Desmoplastic melanoma of the head and neck: histopathologic and immunohistochemical study of 28 cases.

Studies of the immunohistochemical profiles and clinical course of desmoplastic melanoma have produced conflicting results. We identified 28 cases of desmoplastic melanoma after a search of our files for spindle cell neoplasms of the head and neck from 1960 through 1995. The 17 male (61%) and 11 female (39%) patients averaged 65 years of age. The cheek was the most common location (12 cases, 43%). The average length of follow-up was 5 years. Overall 5-year survival rate was 46%. Melan A and tyrosinase positivity (P = 0.0195), smooth muscle actin positivity (P = 0.0328), tumor size (P = 0.0297), and tumor thickness (P = 0.0419) were significantly associated with local progression-free survival. No histologic or immunohistochemical marker was associated with overall or metastasis-free survival.

Intraoperative radiotherapy for head and neck and skull base cancer.

BACKGROUND: The purpose of this study was to evaluate the use of intraoperative electron beam radiotherapy (IORT) as an adjuvant modality in the treatment of advanced head and neck and skull base cancer. METHODS: Between 1991 and 1996, 34 patients with squamous cell carcinoma (SCCA) and 10 patients with non-SCCA were enrolled in this prospective nonrandomized clinical trial. Most patients had been previously treated with combinations of surgery, external beam radiotherapy, and chemotherapy. The most frequent sites treated were the skull base (56%) and the neck (44%). IORT was delivered in a dedicated operating room suite with energies of 6 to 15 MeV (6 MeV most commonly used) at doses of 12.5 to 22.5 Gy. RESULTS: At 2 years overall and disease-free survival was 32% and 21%, respectively, for the SCCA patients and 50% and 40%, respectively, for the non-SCCA patients. Tumor control rates at 2 years in the IORT field were 46% for the SCCA patients and 52% for the non-SCCA patients. For squamous cell histology, survival in patients with microscopic residual tumor did not differ from those with no residual tumor, but they both had significantly longer disease-free survival than those patients with gross residual at the time of IORT (p =.03), with a trend toward longer overall survival (p =.09). The only complication directly attributable to IORT was a neuropathy in a patient who received an IORT dose of 22.5 Gy (cumulative dose 130.1 Gy). CONCLUSIONS: IORT at a dose of 12.5 Gy is safe and produces tumor control and survival for patients likely to have microscopic residual disease in sites difficult to resect such as the skull base.