Saturday, May 24, 2008

What Should You do if your Primary Care, or Endocrinologist tell You that Your Blood Calcium is Elevated and you need Surgery to Remove a Parathyroid

The most common cause is over-active parathyroid gland activity. Usually a single non cancerous tumor called a parathyroid adenoma. The screening testing is easy. Calcium, parathyroid hormone, and urine studies for calcium and creatine. But once the diagnosis is made the next step is not as easy. The location of the tumor can be anywhere in the neck, and may even be in the chest. Also, there may be co-existent thyroid tumors as well. The standard approach is to do a Parathyroid scan.They are hard to read and will negative even when the tumor is present. Do not go to surgery, without a high frequency parathyroid ultrasound. The experience of the parathyroid ultrasonographer is crucial to the success in finding the tumor. They can be found behind the esophagus, down in the thymic ligament and even in the thyroid. Incidental tumor nodules in the thyroid can be treated at the same time if positive for cancer. The parathyroid adenoma has a distinct look on US. It will be hypoechoic and have many shapes as it is soft. There will be a distinctive polar artery coming to the tumor. The parathyroid ultrasonographer will be able to biopsy the tumor with extremely small needles, and usually needs only one or two passes into the tumor. The chances for fibrosis are rare to none. The sample will be sent for cytology, and the needle washing for PTH. The cytology is not diagnostic, as it looks similar to a thyroid adenoma, but the PTH washing will be very elevated in most cases. With the knowledge that there is only one tumor, and the thyroid is not harboring a cancer nodule, the surgeon can do a quick 15 minute operation to remove the single adenoma. If the thyroid ultrasonographer finds more than one adenoma, or a mass is found in the thyroid, then the usual parathyroid exploration and thyroid removal would be needed. Also, if you have a recurrence after the first surgery, you need to see a expert parathyroid ultrasonographer, to find the abnormal gland. There can be a second adenoma missed on the first surgery, or it can be down in the chest. A CT of the Chest can help find that rare variation.

An endocrine neck lab such as mine, or a referral to a clinical thyroidologist with expert ultrasound experience in handling parathyroid localization procedures and biopsies can help your endocrinologist find your tumor.

Do it right the first time, and avoid an unnecessary long exploratatory surgery, or at least know that it is necessary because you had multiple parathyroid masses, or had a tumor nodule in the thyroid as well.
Case Presentation:
46Y/O Female with high Calcium and Blood PTH has parathyroid disease.
A second opinion was requested by her endocrinologist to help locate the adenoma.
Prior para thyroid scan was negative. Neck High frequency ultrasound was negative for locating it until I put 2 pillows under her back and with her neck hyperextended, I was able to see the right upper parathyroid which had been displaced to the area behind the esophagus. The thyroid gland was also abnormal. A 1.6 cm nodule was located in the right lobe.It had abnormal ultrasound changes suggestive of cancer. The biopsy of the parathyroid was done first. a washing for PTH was 56,000, and the cytology was consistent but not diagnostic,resembling a follicular neoplasm.The biopsy for the thyroid nodule was positive for papillary thyroid cancer. Prior to surgery, a lymph node mapping was done to see if neck nodes were invaded by thyroid cancer. The neck node ultrasound mapping was negative. The surgeon was told that because of the thyroid cancer the minimal surgery was not indicated, and a total thyroidectomy and central compartment node removal had to be done. The single adenoma was easily located behind the esophagus and the patient continues to have normal calcium 6 months after surgery.
We call that a "TWOfer". Two diseases with one surgery!

Good Luck,


Endocrine Neck Lab of Southern California
Dr.G. is the thyroid and parathyroid ultrasonographer

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