Parathyroid: Symptoms, Diagnosis & FAQs

hello i'm dr gigi abate i'm an endocrinologist at the mayo clinic in jacksonville florida my clinical and research interests include metabolic bone disease and calcium and parathyroid disorders i've been practicing endocrinology with emphasis and parathyroid disorders and bone disorders for about 10 years as part of a multi-disciplinary team that treats patients with parathyroid disease and i treat patients who have been diagnosed with parathyroid disorders coming for a second opinion those patients coming in with symptoms that cannot be explained and seeking solutions for their symptoms in addition to patients referred to us with high elevated calcium for further workup my name is john casler i'm a head and neck surgeon here at mayo clinic in florida my practice is almost exclusively involved in the treatment of tumors in the head and neck area about a half of my practice is related to treatment of endocrine tumors in the head neck area specifically thyroid and parathyroid disorders i've been practicing for about 30 years i've seen a lot of changes in head and neck surgery we've tried to incorporate those changes into our practice here specifically as they relate to treatment of thyroid and parathyroid disorders so to start off uh we just we both want to mention to you that we're speaking to you without masks because we're in the safety of our offices closed doors social distancing during covet era today we'll be discussing with you about parathyroid glands how they affect us gigi can you tell us a little bit about the parathyroid glands what are they what do they do sure to start off parathyroid glands are four little glands located behind the thyroid gland so we all know the thyroid gland is located on the front part of our neck right over the trachea it's a small little butterfly shaped gland behind the thyroid gland and it works completely different from the thyroid gland there are four little glands called parathyroid glands there is size of rice grain very small and their function is to regulate calcium in the body calcium is very important hormone that is important for brain function from muscle function and for bone strength therefore i call these parathyroid glands sort of a thermostat for calcium regulation so if you have too much calcium in the blood which is not a good thing to have then their job is to make sure that that calcium is excreted through the kidneys and and some of it is reabsorbed back into the bone so we don't have too much calcium in the blood if you have too little of calcium then they send out a signal called parathyroid hormone and in turn this pth also called parathyroid hormone goes to the bone and gets calcium out of the bone and also helps us to reabsorb calcium from the gut and allows us to absorb calcium from the kidney so that overall the calcium in the body is going to be at adequate level for our body to function most people like i mentioned have four glands however some individuals have a fifth one and it could be located anywhere in the upper part of the neck or it could be somewhere in the chest now when the thermostat is functioning properly the calcium is appropriate in the blood the problem comes whenever there is a dysregulation in the thermostat or the parathyroid glands are not working properly so john tell us about what causes these parathyroid glands to malfunction and and uh what are some of these tumors that we're looking at well um gigi there basically are two categories of tumor tumor is mean just means advanced the first category is something called a neoplasm a neoplasm is an abnormal new growth of cells in a parathyroid gland now these neoplasms can be either benign or malignant fortunately 99 of parathyroid neoplasms are benign and the nine parathyroid neoplasms are called adenomas in patients that have primary hyperparathyroidism about 85 to 90 percent of patients will only have a single adenoma or a single benign tumor in five to ten percent of cases there could be multiple adenosines now malignant parathyroid tumors are very rare they represent less than one percent of all parathyroid tumors and what's interesting their initial presentation is often quite different than normal benign parathyroid adenomas the parathyroid hormone level is often very high intraoperatively you can see more invasive qualities to the tumor so you can oftentimes get clues both preoperatively and intraoperatively that a parathyroid tumor or neoplasm could be malignant in both cases though benign or malignant parathyroid tumors there is excessive production or excess secretion of parathyroid hormone the second group of tumors is called hyperplasia this usually involves multiple glands in hyperplasia there's an abnormal diffuse enlargement of the gland but once again this is associated with excess production of parathyroid hormone so gigi in a patient with primary hyperparathyroidism what kind of abnormalities would we expect to see on their blood work so good question john so the majority of patients we see have no symptoms and high calcium is picked up because their primary care physician runs a comprehensive metabolic panel or renal profile and on the blood test they note that there's an elevated calcium level typically those are repeated and confirmed to be elevated so the next thing we look at is if the calcium in the blood is high what is your parathyroid hormone doing as it's the master regulator and what we see is either the parathyroid hormone is elevated or in some cases it could be just high normal range which would be inappropriate for someone who has an elevated blood calcium level sometimes we see high calcium in the urine as well so those are the typical findings of hyperparathyroidism and john once someone shows these laboratory abnormalities what are some of the diagnostic imagings that we proceed with well gigi this can be this could be quite challenging these can be very tricky uh in type of imaging that is used for the type of radiologic study that's used can vary from institution to institution if i had one radiologic technique to pick to identify abnormal parathyroid glands here at nato clinic in florida it would be an ultrasound ultrasounds have a very high rate of detection it also has the advantage of being relatively inexpensive and it does not involve radiation exposure to the patient there are some limitations of ultrasound however it usually doesn't pick up tumors that are located deep in the neck or ones that are hiding behind bony structures like the collar bones clavicles or the sternum or breast bone so when they're behind bone ultrasound doesn't pick them up and we have to look at something else there are other techniques that are commonly used one of these are nuclear medicine scanning techniques these are called parathyroid scans or sesta media scans they can be combined with ct scanning to improve detection so these two imaging techniques the sestimidi or parathyroid scan and the ultrasound are the ones most commonly used to detect parathyroid tumors sometimes we're not able to pick up the parathyroid tumor with either the ultrasound or the nuclear medicine studies when that's the case we have to rely on more sophisticated techniques of imaging for example we use something called a 4d ct scan which times the injection of contrast material in such a way to take advantage of the of the imaging characteristics of parathyroid tumors we sometimes we use mris there is a new technique that's on the horizon using pet scanning images to try to detect these tumors that aren't detected by normal means these involve use of new radiological materials or to try to help visualize these tricky tumors so gigi what kind of symptoms do you see in patients that have primary hyperparathyroidis well john that's a very important question so what we see is the majority of patients have no symptoms at all like i said it's picked up because they go in for blood work however there's some vague symptoms to the symptoms can reach from minor mild symptoms to major symptoms so either someone has no symptoms that's picked up by blood work or they could have symptoms like you know depression fatigue bone pain they just don't feel well and they can go from doctor to doctor without really getting a diagnosis and and all they have is an elevated calcium maybe that's been overlooked so that is more of a um you know the the the one of the symptoms to the point of someone can have major symptoms where they have kidney stones uh because they've lost calcium from the bone they can develop osteoporosis and that can lead to fractures and their blood calcium can be so high that they can require hospitalization and they could be you know dehydrated can have kidney injuries so the symptoms can range there's a wide range of ways of presenting with hepa parathyroidism but the most common symptom is just patients do not have any symptoms and john um when we you know once these we're diagnosed hyper parathyroidism and we do imaging and either we find the tumor the enlarged gland or not what are some of the treatment options we currently have for this disease well gigi surgery is is considered the definitive treatment so removing the abnormal gland or glands should get rid of the the problem now surgery though regardless of its type whether you're doing a heart transplant or whether you're doing a mole removal has risk to it so it also has risk of bleeding infection and risk from anesthesia there are some risks that are peculiar to parathyroid surgery as well so in any case we want to make sure that we're doing surgery for the right reasons and that the risks of surgery are clearly outweighed by the benefits of doing it so if a patient has symptoms that we can reasonably attribute to hyperparathyroidism surgery is generally a good option one situation where that's clearly the case is the patient that has kidney stones in patients that have kidney stones or renal stones and evidence of hyperthyroidism those patients will usually benefit from having surgery done there are some situations however where a patient as you've mentioned may not have any symptoms related to the hyperparathyroidism but they would still benefit from having surgery done and there's several situations where that's that's the case those are called indications so there have been conferences where consensus statements have been formed to list the indications where parathyroid surgery may be indicated even though there are no symptoms those would include number one having a serum calcium level that is a full point or one milligram per deciliter that is above the upper limit of normal that's the first indication well that's an indication second indication the second group of indications would be skeletal meaning if you have osteoporosis at any site and you have hyperparathyroidism you would benefit from having the surgery done if you have asymptomatic vertebral fractures you would benefit from surgery as we mentioned there there are some kidney related issues that would justify or warrant having surgery done if you have decreased urine function and hyperparathyroidism surgery should be considered if you have excess urine excretion of calcium meaning more than 400 milligrams in a 24-hour period you would benefit from having the surgery and as we've mentioned previously if you have kidney stones and hyperparathyroidism you'd benefit from surgery the last indication is age patients that are less than 50 years of age and have documented hyperparathyroidism would benefit from having surgery done because this is a progressive disease it generally gets worse over time and patients that are under 50 years of age will have a long time for this condition to cause lots of problems so those are the those are the reasons why we would consider doing parathyroid surgery now while we're on the topic of surgery let me just briefly describe what's involved in the surgery so first of all surgery to take care of parathyroid tumors is called a parathyroidectomy it's generally performed under general anesthesia meaning the patient goes completely to sleep this on occasion though we will do the operation under local anesthesia so you make a small incision in the lower part of the neck in the middle kind of where my necktie is we dissect down to where we think the tumor might be based on our pre-operative localization studies if we find a tumor in that location we take it out and send it to the lab if we don't find a tumor in that location we need to investigate other areas where the tumor could be located some surgeons advocate exploring all the parathyroid glands in all cases this is controversial and is kind of beyond the scope of our discussion today if general anesthesia is used a nerve monitoring breathing tube is used to monitor vocal cord nerve function during the surgery since the vocal cord nerves are located in close proximity to the parathyroid glands in addition to testing the abnormal parathyroid gland in the lab we also will oftentimes or usually check the patient's parathyroid hormone levels during the surgery so removal of the parathyroid tumor should result in a significant drop in the patient's parathyroid hormonal level if the level doesn't drop sufficiently we have to suspect that there might be an additional tumor around and we need to try to investigate that and find it after we have successfully completed the removal of the abnormal parathyroid tissue we close the wound we wake the patient up and take them to the recovery room after a couple of hours of observation in the recovery room most patients are able to leave the hospital so gigi are there a patient that may not be a good surgical candidate or doesn't want surgery are there any alternatives for managing or treating hyperparathyroidism sure that's a good question and of course as you mentioned that the number one treatment for this disease is to go for cure which is surgery however in some cases where patients either don't want to have surgery or they you know their calcium is high parathyroid hormone is high and they're not surgical candidates for whatever reason either they're too sick to have surgery um or they're on certain medications that uh you know preclude them from having surgery and that case um there is a medication um it is something called sensapar it's been out for many years and this medication is sort of a band-aid what it does is it lowers the calcium it lowers the parathyroid hormone and prevents complications that comes from having those two high levels but this would be something that a person would have to take mostly for the rest of their lives it has its own side effects but it medication is an option although it is a second line treatment another thing i see often is as you mentioned john that there are indications there are definitive indications for surgery and per the guidelines and those are if somebody has high calcium above one limit upper the upper limit of normal for calcium if they have kidney stones osteoporosis however how about in those individuals who have just mild calcium elevation of 10.5 10.6 parathyroid hormone is fine and their bone density looks normal and in that case you know surgery is an option however if they don't want to have surgery we know from several studies that individuals with milder disease can be observed for many many years without having developing any complications from that which complications such as a rise in the calcium at a dangerous level or developing kidney stones or developing osteoporosis so in those patients with milder cases and choose not to have surgery for whatever reason then observation would be an excellent option and that would include obtaining a blood calcium level every six months and getting a 24 year in collection you know once or every every year every two years make sure they're not developing kidney stones and make sure that they're getting bone density to check on the status of the bone every every two years every one to two years depending on where they are on that bone density measurement so these are the non-surgical treatment goes from observation to uh medical medical therapy that we offer patients and you know we see patients with um other things that can cause high calcium so that's also something that we need to talk about and exclude as well before we go with surgery as you know john that not everybody who has high calcium has hyperparathyroidism so that's one of the things we always consider also before we go for surgery so we do a comprehensive evaluation before we diagnose somebody with a primary parathyroidism which implies that there's enlargement or a tumor on the parathyroid gland so we spend a lot of time making those evaluation and making those determinations and once the decision is made that you've got primary parathyroidism then um it's up to the patient and their uh physician to make that decision as to surgery is the better option or if observation or surgical treatment non-surgical medications such as sensitive part would be the best option that's a very good point gg there are a lot of causes for high calcium and not all high calcium is hypoparathyroidism there are some conditions that can mimic hyperparathyroidism for example there are some kidney abnormalities that can mimic hyperparathyroidism we certainly don't want to be doing an operation in the net when the patient has a kidney problem so one of the things that i enjoy uh working here is that i get to collaborate with endocrinologists like yourself so that if there are any questions we can work through the subtleties of a clinical presentation to make sure that we're always doing the right thing for the patient uh given their individual circumstances and to add on to that you know one of the things also i see is rare things you know one of the advantages of working in a collaborative tertiary care center is not everybody who comes with hyperparathyroid symptoms or parathyroid something that looks like hyperparathyroidism only has hyperparathyroidism so there are other syndromes that go along with primary hypoparathyroidism so we always keep our minds open when we see individuals outside of surgery we always try to ask for a family history and we ask for other look at the whole general picture of the patient to determine that is it really a one-time disease we're looking at or is there a syndrome or is it a genetic condition and we have an excellent geneticist once you know if there's a question like that arise things like multiple endocrine neoplasia etc so um you know that's one of the things i enjoy about working in a multidisciplinary system in a tertiary care center is that it's not always just treating what we see in front of us there we always go in depth and look at could there be some other conditions that could be presenting with parathyroid disorder but it could be more serious or something else we need to be looking for in that individual so i think we do a comprehensive assessment in endocrinology and um and then one thing i wanted to ask you john is secondary you know someone who has surgery somewhere else or here and they would have a failed surgery meaning their parathyroid hormones still elevated after surgery and in that case one of the things we do in endocrine is we re-evaluate again and we say is it because you know they're not getting enough calcium now um or was there some other diagnoses we should be worried about or is a tumor somewhere else in the body what are your thoughts on that once when you see patients like that well you raise a very good point um fortunately the cure rate for hyperparathyroidism is quite high with parathyroid but for whatever reason we do come across patients that that surgery has failed to cure in that case i think the best thing to do is to take a step back number one confirm that they really do have hyperparathyroidism so confirming the diagnosis in recurrent or persistent hyperparathyroidism is essential secondly from my standpoint i want to get the records from the prior surgical procedure i want to see where the surgeon has been what was removed i want to be able to correlate that with the final pathology to make sure that parathyroid tissue was removed was it a malignancy was it was it benign parathyroid tissue then we need to do a thorough search to try to see where the remaining problem might be and that's oftentimes when we get into some of the more sophisticated imaging techniques but you want to do your homework on this you want to make sure that when you go to the operating room you really have a very good idea where the tumor is particularly in these current cases because you'll have to be dealing with scar tissue and things like that and any time you're doing business surgery the risks are generally higher and john so what should patients be looking for in a surgeon once they do get the diagnosis of primary hyperthyroidism uh i mean i i know that the most important thing is a good surgeon right to cure this disease and so what are some of the things that they should be looking for and they should be asking well i think it's important it's like anything that we do in life the more you do something the better you get at it so with with thyroid and parathyroid surgery the more of these procedures that a certain performs the better they tend to get at it so i think it's very appropriate to for patients to ask the surgeon how many of these do you perform a year what kind of results do you have things like that and patients shouldn't feel bashful about doing that i think it's also important gg to be able to have a team of physicians around the patient that are able to manage not just the surgical but the medical issues related to this and we haven't touched on this but as you know there are other forms of hyperparathyroidism in some of those patients that have renal induced hyperparathyroidism or hyperparathyroidism related to the transplant oftentimes have many medical problems so it's important we have a team that gathers around that patient to make sure they have optimal results not just during surgery but in the post-operative course as well absolutely you know one of the things i see is calcium management afterwards you know you've been hearing on and all the time don't take calcium don't take calcium and um you know after surgery and all of a sudden you have to take calcium and so those that's important that has to be regulated and as i mentioned previously too is you know looking back and saying is this a one-time parathyroid disorder or is there something else that we should be considering and then also other diseases like you mentioned john is you know is there some other cause for high calcium one thing i didn't mention i'm glad you brought that up is there's something that mimics primary hyperparathyroidism and it's called familial hypocalceuric hypercalcemia and what that means is that in certain individuals it's more of a genetic problem is that their parathyroid gland senses only high level of calcium and in that case it's a benign condition it's it's their body it's a that's the only way you sense calcium so that high calcium is normal and what you see in these individuals is they've been told they've had high calcium since their 20s you know every time they get blood work done and the way you make diagnosis is getting a 24-hour urine collection and getting to see how low the calcium is so these are all important things that are uh that really need to be evaluated and then before we head to before we head to surgery or treatment observation so to me i believe and i think the initial work up is probably the most important thing and once you completely conclude that's the problem then finding an excellent surgeon who does this on a regular basis was very good experience and i think that would set anybody up for success and having a team um you know to follow them before and after gigi it's been a pleasure chatting with you about hyperparathyroidism something i think we both enjoy taking care of so thank you for spending the time and thank you to our audience too for listening and please feel free to contact us if you have any questions well thank you i agree thank you so much

Channel: Mayo Clinic

Views: 12,099

Keywords: Mayo Clinic, Health Care (Issue), Healthcare Science (Field Of Study), parathyroid, Hyperparathyroidism, Endocrinology, Otolaryngologist, ENT, Head and Neck

Id: -cewAcAQk6U

Length: 27min 42sec (1662 seconds)

Published: Fri Oct 09 2020