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Intraoperative

Identification of Ectopic Parathyroid Adenomas at the Cervicothoracic Junction Using Probe-Based Near-Infrared Autofluorescence (PTeye®). https://doi.org/10.1016/j.arbres.2026.07.004 Copy Export citation to RIS format

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Bibliography Corresponding author [email protected] Corresponding author. Article information Full Text Bibliography Download PDF Statistics Tables (1) Table 1. Intraoperative and pathological findings of ectopic parathyroid adenomas at the cervicothoracic junction.

Full Text To the Director, Ectopic parathyroid adenomas located at the cervicothoracic junction pose a surgical challenge. Their deep location, scarcity of reliable anatomical landmarks, and frequently limited or discordant preoperative imaging may hinder intraoperative identification and lead to more invasive surgical approaches. Near-infrared autofluorescence (NIRAF) is increasingly used for intraoperative identification of parathyroid tissue.

Probe-based devices such as PTeye® have shown high accuracy for identifying eutopic glands [1,2] and provide immediate, label-free, radiation-free detection [3]. However, autofluorescence in hyperfunctioning glands may be more heterogeneous and weaker than that observed in normal parathyroid glands [4]. A recent multicenter randomized trial confirmed that probe-based NIRAF improves parathyroid identification during endocrine neck surgery [5], but evidence regarding its use in deeply located ectopic cervicothoracic adenomas remains limited.

We reviewed a total of 6 consecutive patients with primary hyperparathyroidism caused by an ectopic parathyroid adenoma who underwent surgery with PTeye® guidance over an 18-month period. The adenomas were located in the deep retrotracheal space in 2 patients, the retroesophageal space in 2, the low paracarotid region in 1, and the upper mediastinum with cervical accessibility in 1. Preoperative technetium Tc 99m-sestamibi single-photon emission computed tomography/computed tomography correctly localized the adenoma in all 6 patients.

None of the procedures were reoperations, and all were performed by the same surgeon. In none of the cases was the gland visible after the cervical incision; nevertheless,



all adenomas were resected through a minicervicotomy without sternotomy or a combined surgical approach. PTeye® guided dissection toward parathyroid tissue before the adenoma was directly exposed.

Near-infrared light, with an excitation wavelength of approximately 785nm and an emission wavelength of approximately 820nm, undergoes less scattering and absorption than visible light. In addition, the contact probe can access confined retrotracheal and retroesophageal planes. Consequently, the autofluorescence signal could be detected through overlying tissue, enabling subsurface localization of concealed glands, unlike line-of-sight imaging systems.

The autofluorescence pattern was homogeneous in some adenomas and heterogeneous, with brighter peripheral areas, in others [4]. The small sample size precluded assessment of associations between autofluorescence patterns and histological features, adenoma size, or depth; therefore, these findings should be considered hypothesis-generating. Intraoperative parathyroid hormone (PTH) levels were measured at baseline and 10min after excision, with biochemical cure defined according to the Miami criterion.

Mean serum calcium decreased from 11.8mg/dL (range, 10.9–12.5mg/dL) before surgery to 9.48mg/dL (range, 8.5–10.3mg/dL) 1 month after surgery. Mean PTH decreased from 141.5pg/mL (range, 90–276pg/mL) to 30.48pg/mL (range, 18.9–53pg/mL). All postoperative values were within the reference ranges, and no patient developed hypocalcemia.

At a median follow-up of 12 months (range, 8–15 months), all patients remained normocalcemic and had normal PTH levels. No intraoperative frozen-section analysis was performed; therefore, parathyroid tissue was confirmed only by final histopathological examination, which demonstrated an adenoma in all 6 cases. This represents a limitation of the study.

No complications occurred. The longer operative time in the patient with the mediastinal adenoma, 70min, reflected the greater depth and complexity of the required dissection. The detection ratio, defined as tissue autofluorescence normalized to the thyroid baseline and considered positive at values>1.2 [2], ranged from 1.5 to 1.8 (Table 1).

Table 1. Intraoperative and pathological findings of ectopic parathyroid adenomas at the cervicothoracic junction. Case Anatomical location Adenoma weight (mg) Largest dimension (mm) Detection ratio (PTeye) Operative time (min) 1 Deep retrotracheal 800 29 1.6 45 2 Deep retrotracheal 600 16 1.7 52 3 Retroesophageal 360 14 1.5 38 4 Retroesophageal 500 18 1.8 42 5 Low paracarotid 600 23 1.6 35 6 Upper mediastinum 400 17 1.7 70 All procedures were performed through minicervicotomy.

All specimens were confirmed as parathyroid adenoma on final histopathology; intraoperative frozen-section analysis was not performed. PTeye, near-infrared autofluorescence probe.

Conclusions

Probe-based NIRAF enabled the localization and resection of all 6 ectopic parathyroid adenomas at the cervicothoracic junction through a minicervicotomy, avoiding sternotomy or a combined surgical approach. Its principal contribution is immediate,



label-free spatial guidance during dissection. Intraoperative PTH monitoring confirms biochemical cure but does not aid localization; radioguided surgery requires administration of a radiotracer and access to a nuclear medicine department; and indocyanine green angiography assesses tissue vascularization rather than specifically identifying parathyroid tissue.

Therefore, NIRAF should be regarded as a complementary intraoperative tool [3]. Although the available evidence remains limited, our experience suggests that probe-based NIRAF may be a useful adjunct for difficult-to-localize ectopic parathyroid adenomas and warrants evaluation in larger series. Declaration on the use of artificial intelligence During preparation of this manuscript, generative artificial intelligence tools were used solely to assist with drafting and language editing, including improvements in clarity and style.

The authors confirm that the scientific content, clinical data, interpretation of the results, and conclusions were entirely developed, reviewed, and validated by the authors. Ethical responsibilities This retrospective case series of routine surgical care was based on anonymized data. Under the applicable institutional regulations, specific approval from an ethics committee was not required, as confirmed in writing by the institution's Research and Innovation Directorate.

The study was conducted in accordance with the Declaration of Helsinki, and written informed consent was obtained from all patients.

Funding

None declared. Conflicts of interest None declared. References [1] G. Thomas, M.A. McWade, C. Paras, E.A. Mannoh, M.E. Sanders, L.M. White, et al. Developing a clinical prototype to guide surgeons for intraoperative label-free identification of parathyroid glands in real time.

Thyroid., 28 (2018), pp. 1517-1531 http://dx.doi.org/10.1089/thy.2017.0716 | Medline [2] G. Thomas, M.A. McWade, J.Q. Nguyen, M.E. Sanders, J.T. Broome, N. Baregamian, et al. Innovative surgical guidance for label-free real-time parathyroid identification.

Surgery., 165 (2019), pp. 114-123 http://dx.doi.org/10.1016/j.surg.2018.04.079 | Medline [3] C.C. Solórzano, G. Thomas, N. Baregamian, A. Mahadevan-Jansen. Detecting the near-infrared autofluorescence of the human parathyroid: hype or opportunity?.

Ann Surg, 272 (2020), pp. 973-985 http://dx.doi.org/10.1097/SLA.0000000000003700 | Medline [4] E. Kose, B. Kahramangil, H. Aydin, M. Donmez, E. Berber. Heterogeneous and low-intensity parathyroid autofluorescence: patterns suggesting hyperfunction at parathyroid exploration.

Surgery, 165 (2019), pp. 431-437 http://dx.doi.org/10.1016/j.surg.2018.08.006 | Medline [5] A.G. Cousart, C.M. Kiernan, P.A. Willmon, G. Thomas, T.S. Wang, P.G. Gauger, et al. Near-infrared autofluorescence for parathyroid detection during endocrine neck surgery: a randomized clinical trial.

JAMA Surg, 160 (2025), pp. 936-944 http://dx.doi.org/10.1001/jamasurg.2025.2233 | Medline Copyright © 2026. SEPAR Tables (1) Table 1. Intraoperative and pathological findings of ectopic parathyroid adenomas at the cervicothoracic junction.

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📌 Intraoperative Identification of Ectopic Parathyroid Adenomas at the Cervicothoracic Junction Using Probe-Based Near-Infrared Autofluorescence (PTeye®) (Fuentes de Ropel)
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