Parathyroid glands

Primary hyperparathyroidism

Primary hyperparathyroidism is caused when one or more parathyroids cause an overproduction of a hormone (parathyroid hormone). The cause may be a benign tumor of the parathyroid gland called an adenoma. It can be a benign hyperplasia that affects more glands (hyperplasia). Very rarely it can be a cancer (malignant tumor).

The cause of these tumors is unknown. According to some theories it may be the previous exposure to radiation to the head and neck area, the use of lithium. More rarely, it can be a syndrome that can occur in specific families.

Diagnosis

Parathyroid adenoma or carcinoma releases high levels of parathyroid hormone (PTH). Through the action of PTH on the bones, intestines, kidney, there is an increase in calcium levels in the body. Therefore, blood is tested for both PTH and calcium levels. Elevated levels of calcium and PTH without other causes, such as kidney failure are diagnostic of the disease.

Normal levels

Although the values differ in different diagnostic centers, the average parathyroid hormone (PTH) is between 10 and 65 pg / ml. Increased PTH levels are a factor that may lead a physician to suspect hyperparathyroidism. However, it is important to consider all of a patient’s factors and not rely on one for diagnosis.

When does parathyroid hormone rise?

The level of calcium in the body is regulated by the parathyroid glands. Low levels of calcium in the body stimulate the gland to release PTH. Once the calcium level returns to normal, the gland stops releasing PTH. However, when the tumor or cancer originates in the parathyroid gland, this self-regulation is disrupted and the release of PTH is uncontrolled.

Normal calcium high parathyroid hormone

If your calcium level is normal and your parathyroid hormone (PTH) level is high, it is most likely due to the early onset of hyperparathyroidism. Some patients will eventually develop the complete disease and its complications. Many will never develop the classic form of the disease.

Although surgery in the case of normal calcium with a high PTH normalizes PTH levels, its long-term benefit is not known.

High calcium normal parathyroid hormone

When the calcium level is high, the normal reaction of the parathyroid glands is to stop producing parathyroid hormone, so the parathyroid hormone must be very low. If calcium is elevated and parathyroid hormone is still produced in significant amounts, this may be a sign of primary hyperparathyroidism.

It is important to see your doctor to discuss these possibilities and your doctor may recommend additional tests to see if there is a problem with your parathyroid glands.
In addition, there are certain conditions or medications that can cause high calcium levels with low or normal levels of parathyroid hormone (PTH). These conditions include: Sarcoidosis, multiple myeloma, Paget and high levels of vitamin D.

Advanced cancers that metastasize to bone, such as breast cancer, lung cancer, and kidney cancer, cause bone breakdown and calcium release

High calcium

Parathyroid hormone (PTH) removes calcium from the bones. In the gut, PTH indirectly causes an increased absorption of the calcium we eat. In the kidney, PTH inhibits the elimination of excess calcium by promoting calcium reabsorption. All of these mechanisms represent an increase in blood calcium.

Parathyroid cancer

Parathyroid cancer is extremely rare. Cases of parathyroid cancer make up less than 1% of the total number of patients with primary hyperparathyroidism. Patients with parathyroid cancer typically have very high calcium levels (greater than 14 mg / dL). They also have very high levels of parathyroid hormone (PTH) (usually greater than 300 pg / mL or more). The diagnosis of parathyroid cancer is made by the patient’s symptoms, blood tests and findings in the operating room.

What is parathyroid cancer?

Parathyroid cancer is a clinical diagnosis, which means that the diagnosis of parathyroid cancer is made by the patient’s symptoms, blood tests and findings in the operating room. The pathologist may not be able to tell if it is cancer, even if he looks at samples under a microscope. The best chance of treating parathyroid cancer is the early diagnosis of the disease and its immediate removal.

Treatment

The best chance of treating parathyroid cancer is to diagnose the disease early and have the patient undergo surgery. By the time he is diagnosed, parathyroid cancer may have spread to other organs such as the thyroid.

The best treatment for parathyroid cancer is surgical removal of the parathyroid cancer along with the thyroid lobe on the same side. Chemotherapy and radiotherapy do not help as much as parathyroid cancer.

Fortunately, parathyroid cancer usually develops slowly and patients can be re-operated to remove the disease as it recurs.

Scintigraphy

In most patients with primary hyperparathyroidism (80%), only one of the four parathyroid glands is sick. One such detection test is the sestamib scintigraphy. This involves injecting a small amount of special radioactive material intravenously and taking pictures of the chest, neck and head.

The advantages of the test are its widespread availability and its ability to detect abnormal glands located outside the neck.

Negative detection attempt

Imaging studies help the surgeon determine if a patient is a candidate for a focused parathyroidectomy (an operation where the surgeon examines and removes only one abnormal gland). Imaging studies do not determine if the patient has hyperparathyroidism, but only help determine the type of surgery that is needed. A patient with negative imaging studies will probably need a traditional neck examination on both sides.

In this technique, all four parathyroid glands are examined in the operating room. During the operation, the surgeon determines which glands are diseased based on their size and appearance.

Investigation

Examination of both sides of the neck is the traditional surgical approach to parathyroid surgery. This operation involves examining and examining all 4 parathyroid glands (usually two on the right and two on the left). This allows the surgeon to determine if there is a single abnormal parathyroid or if more than one is abnormal.

This surgery has been shown to be extremely successful over time with a success rate of 95% or more when performed by an experienced surgeon.

Intraoperative parathyroid measurement

The intraoperative parathyroid hormone (PTH) test is definitely used by specialized surgeons when designing a minimally invasive approach. Monitoring PTH involves examining the patient’s PTH level both before and after removal of the abnormal gland.

The level of PTH drops in the body, after the removal of the gland. This allows the surgeon to control the success of the operation. If the parathyroidectomy was successful while the patient is under anesthesia. If the PTH level remains high, the surgeon may need to perform an examination to locate the remaining parathyroid glands.

Scar size

The size of the scar depends on the type of surgery performed and the experience and specialization of the surgeon. Experienced and specialized surgeons perform very small incisions and have excellent results.

Absence of pain

Almost all of our patients only feel a slight discomfort, for which they do not need to take painkillers.

Voice security

The risk of losing your voice is extremely small with parathyroid surgery. However, nowhere in the world and in any surgeon is it zero. Most experienced parathyroid surgeons have a 1-2% rate of permanent hoarseness after surgery. Complete loss of your voice would be extremely rare. This would only happen if the nerve responsible for speech is severely injured on both sides or cut.

If there is permanent damage, there are treatments that can be applied to restore the tone of your voice as close to normal as possible.

How he feels postoperatively

The decay problem after surgical extension storage is partly due to the response listed in the analogy. The side effects of anesthesia are sought after. The project will make me feel like I am doing the results from the comments you had before your surgery (eg fatigue). Students have to do with the results, the non-surgical extension required.

Numbness

Numbness and tingling in your lips or fingers occurs when your body feels reduced calcium levels. This is a common post-parathyroid surgery. You can feel these symptoms even when your calcium levels have returned to normal, but since you were living with much higher calcium levels, your body feels that the normal level is not enough.

This could also be a sign that the parathyroid glands are not working yet. It can happen if all four of your glands are removed and part of one is implanted.

In this case it will take up to 6 weeks for the normalization of calcium levels.
You should contact your surgeon if these symptoms occur. You should discuss a plan for treating these symptoms with your surgeon before you leave the hospital.

Feeling tired

Research has shown that surgery can improve fatigue and improve the quality of life for the majority of patients (up to 80% to 95%). However, it is important to note that although many patients notice improvement, not all patients see it because there are many other possible causes for these non-specific symptoms.

Patients with hyperparathyroidism have been shown to have more neuropsychological symptoms, including fatigue, than the general population. However, it is difficult to determine if hyperparathyroidism is the real cause of fatigue, as there are many other reasons that could contribute.

Memory

Memory has been found to be impaired in many patients with hyperparathyroidism. The way in which primary hyperparathyroidism causes memory impairment is unclear. Studies have shown that patients with primary hyperparathyroidism show improved memory (up to 80% of patients).

Nephrolithiasis

Surgery for primary hyperparathyroidism will not eliminate existing kidney stones, but will reduce the formation of new stones. A small group of patients (approximately 10%) will continue to form stones after parathyroid surgery.

Bone mineral density

Studies show that after successful parathyroid surgery, bone density will improve by 8 to 12% and the risk of fracture will be reduced. The improvements are measurable one year after surgery. These will continue for the next ten years. All patients with hyperparathyroidism, who have from mild to severe disease, have significant bone health benefits after surgery.

Relapse

It depends on whether you have the most common disease of one gland (85%) or the disease of multiple glands (15%) or the rarest parathyroid cancer (<1%). The risk of recurrence can be 1%, 30% or up to 70%, respectively.

Persistent hyperparathyroidism

Persistent hyperparathyroidism means that your calcium level did not return to normal after your parathyroid was removed. This is usually caused by a “lost gland”, the inability to identify. . Is caused by non-removal of the abnormal parathyroid gland during the initial operation. It is well established that surgery performed by an experienced parathyroid surgeon has a success rate of over 95%. Failures are due to ectopic glands, the presence of an additional fifth gland and / or unrecognized multiple gland disease.

In reoperations, unfortunately, it has been shown that the majority of the glands found are a simple gland and are in their normal anatomical position. Less experienced surgeons could have a failure rate of up to 30%.

Recurrent hyperparathyroidism means that your calcium level rises again after a period of normalization. This period occurs up to 6 months after your parathyroid surgery. This is usually caused by the re-growth of abnormal parathyroid tissue.

Reoperation

This is a problem because parathyroid surgery is technically difficult. It has higher complication rates as well as failure rates. This is why we emphasize the importance of getting it right the first time.
The endocrinologist or endocrine surgeon must first confirm your diagnosis, in which case a complete set of tests must be repeated. There should usually be a higher limit to having your surgery again.

The decision to reoperate is multifactorial. If you have a mild elevation of calcium, without a significant effect on your bone, kidney or neurological function, it may be best to seek medical attention to reduce your calcium level.
If you are going to have surgery, you will need to get all of your medical records from your initial surgery. You may need a more extensive evaluation. This includes additional imaging study, evaluation of vocal cord function, etc.