The molecular genetic changes from certain endocrine tumors are already understood, reflecting as they do the etiology of these sporadic familial disorders. This already has clinical consequences to the treatment of familial endocrine tumors, which often appear in the course of syndromatic disorders. These consequences consist in slight changes to surgical technique, the search for other active and usually endocrinal tumors, and examination of family members for other gene carriers (of disease-specific mutations) and the most suitable prophylactic tumor therapy. In contrast, for sporadic endocrine tumors there exists far less clinically relevant knowledge. Starting with anamnesis and clinical findings of active endocrine tumors, we discuss the current possibilities for molecular genetic determination of disease-specific mutations (germline and tumor DNA) and their effect on surgical procedure.

Benign adrenal gland tumors smaller than 6 cm are nowadays the indication for minimally invasive surgery. Until now there has been no significant difference between retroperitoneoscopic and transabdominal adrenalectomy. Intestinal adhesions could be a contraindication against transabdominal laparoscopic adrenalectomy, and therefore the retroperitoneoscopic approach could be an advantage in these cases. A prospective study concerning this question has not been published yet. Our clinical investigation here includes 114 adrenalectomies during the last 5 years. We show that in any case of abdominal preoperation, laparoscopic adrenalectomy can be performed by transabdominal approach and without conversion to open surgery. Discussed are the different indications for laparoscopic adrenalectomy, operating time, conversion rate to open surgery, and amount and type of abdominal preoperation. We compared patients with and without abdominal preoperations.

Die molekulargenetische Veränderungen einiger endokriner Tumoren sind zu Teilen aufgeklärt und spiegeln die ätiologische Grundlage der Entwicklung dieser sporadischen und familiären Erkrankungen wider. Für familiäre endokrine Tumoren, die oft im Rahmen von Syndromerkrankungen entstehen, hat dies schon jetzt klinisch praktische Auswirkungen. Sie liegen im teilweise veränderten chirurgischen Vorgehen, in der Suche nach weiteren, meist endokrin aktiven Tumoren und in der Untersuchung von Familienmitgliedern zur Entdeckung weiterer Genträger (Träger der spezifischen Mutation) und gegebenenfalls einer prophylaktischen Tumortherapie. Für sporadische endokrine Tumoren verfügen wir dagegen über weit weniger klinisch verwendbare Erkenntnisse.

INTRODUCTION:Cystic lesions of the parathyroid glands are uncommon, and rare are those that cause primary hyperparathyroidism. Preoperative diagnosis can be challenging and some of these tumors might be misinterpreted as parathyroid carcinoma. With an expertise of more than 1700 patients operated on primary hyperparathyroidism, we present six cases with cystic degeneration of a parathyroid gland causing primary hyperparathyroidism in five patients.CASE REPORTS:A woman at the age of 67 presented with hypercalcaemic crisis due to persistent primary hyperparathyroidism after an operation four years ago. As cervical exploration was unsuccessful, sternotomy was performed and a cystic adenoma of a parathyroid gland could be resected from the anterior mediastinum. The second patient - a 63-year-old female with severe hypercalcaemic crisis, operated on under suspicion of a parathyroid carcinoma - had a functional cyst of the parathyroid gland with a parathyroid hormone level of 700,000 pg/ml in the aspirated fluid. Third, operation on a 70-year-old woman with a benign euthyreot goiter and the laboratory findings of primary hyperparathyroidism revealed a cystic adenoma adjacent to the thyroid gland, whose aspirate had a parathyroid hormone level of 1,500,000 pg/ml. In the fourth case of a 67-year-old female with an adenoma of the right inferior parathyroid gland localized by ultrasonography, the cystic parathyroid adenoma was operated on by video-assistance. A cystic structure in the upper mediastinum was diagnosed in the fifth patient, a 66-year-old woman. It was suspected to be a thyroid cyst at the left-lower pole of the thyroid gland. After hemithyroidectomy pathological evaluation revealed a large parathyroid cyst. The last case of a 56-year-old male illustrates the extensive preoperative work-up of a patient with primary hyperparathyroidism who was preoperatively diagnosed as having a thyroid cyst. Final histopathological examination exposed multiple gland disease with a parathyroid adenoma as well as a cystic parathyroid gland.DISCUSSION:Cystic adenomas of the parathyroid glands are often misdiagnosed as thyroid cysts or - in the case of extremely elevated parathyroid hormone levels - even as parathyroid carcinoma. The routine preoperative diagnostic tools, such as ultrasonography or (99m)Tc-sestamibi-scintigraphy, cannot clearly distinguish between these entities and might be jeopardized by mediastinal localization, which is not uncommon in parathyroid adenomas with cystic degeneration.

Einleitung: Intrathorakale Nebenschilddrüsen-Adenome sind eine diagnostische und therapeutische Herausforderung.

Einleitung: Patienten und Methode: Ergebnisse: Schlussfolgerung: Introduction: Patients and methods: Results: Conclusion:

Einleitung: Die Technik des Harmonic-Scalpels (Ultracision™) und des Vessel-Sealings LigaSure™) hat einen festen Stand in der minimalinvasiven und offenen Chirurgie des Bauchraumes und Retroperitoneums erlangt. Inwieweit die Techniken auch Vorteile bei der offenen Präparation der Schilddrüse aufweisen, sollte eine prospektiv randomisierte Studie mit Verwendung der Vessel-Sealings-Technik (Precise™) nachweisen. Patienten und Methode: In einer prospektiv randomisierten Studie an 78 Patienten mit Struma nodosa unter Ausschluss von Patienten mit Morbus Basedow wurden das konventionelle Operationsverfahren und LigaSure™-assistiertes Dissezieren der Schilddrüse miteinander verglichen. Es wurden besonders die Operationszeiten und postoperativen Schmerzangaben gemessen. Ergebnisse: Die Verwendung des Vessel-Sealings (LigaSure™) führt bei der Dissektion der Schilddrüse zu einer Zeitersparnis von insgesamt 26 % (31 min), ohne dass Nachteile bezüglich Nachblutungen, Rekurrensparesen oder postoperativem Hypoparathyreoidismus zu verzeichnen wären. Die postoperative Schmerzangabe wurde bezüglich der Intensität bei den Patienten als tendenziell geringer (n. s.) angegeben. Die Vorteile der Operationstechnik bestätigten sich in der nachfolgenden Anwendung bei 184 Patienten. Zusammenfassung: Die Technik des Vessel-Sealings (LigaSure™) kann, wie auch die Technik des Harmonic-Scalpels (Ultracision™) für die Dissektion der Schilddrüse gefahrlos benutzt werden, mit dem Vorteil einer Reduktion der Operationszeiten um etwa Œ und teilweise einfacherer Operationstechnik.