Surgical management of ectopic mediastinal parathyroid adenomas: a report of three cases highlighting diagnostic and operative challenges

Ectopic mediastinal parathyroid adenomas (MPAs) present unique diagnostic and surgical challenges due to their proximity to vital thoracic structures. Primary hyperparathyroidism (PHPT) is often caused by parathyroid adenomas, with approximately 15–20% of cases involving ectopic parathyroid glands. We report three cases of ectopic MPAs with varied clinical presentations and surgical approaches. Case I involved a 64-year-old woman who had previously undergone an unsuccessful sternotomy. Imaging identified a retrosternal adenoma, which was successfully excised via video-assisted thoracoscopic surgery (VATS). Case II, a 77-year-old man with asymptomatic hypercalcemia and a mediastinal adenoma near the aortic arch, initially underwent VATS, which was converted to thoracotomy due to anatomical complexity. Case III was a 62-year-old man with persistent PHPT after prior neck surgery. Imaging revealed a residual adenoma in the anterior mediastinum, which was removed using VATS. All patients achieved biochemical cure postoperatively. These cases highlight the importance of advanced imaging modalities, individualized surgical planning, and, where feasible, the use of minimally invasive techniques. Intraoperative PTH monitoring was not utilized due to limited availability, but it is recognized as a valuable adjunct when available. Anatomical variability and prior surgeries can complicate the management of MPAs. Tailored, imaging-guided surgical approaches are essential for optimal outcomes. VATS is a safe and effective method when feasible, though open surgery remains necessary in select complex cases.