Every year 100,000 Americans discover that they have high blood calcium levels caused by overactive parathyroid glands in the neck. Surgery is necessary to cure the hypercalcemia if the blood calcium exceeds 11.0 mg/dl or if the parathyroid hormone excess is causing kidney stones, ulcer disease, pancreatitis (severe pancreatic inflammation and belly pain) or bone loss. 85-90% of the time, the enlargement involves only one out of the four parathyroids and minimally invasive removal of the enlarged gland will result in a persistent normalization of the serum calcium and clinical cure. Finding the enlarged parathyroid gland (adenoma) or glands (adenomas) can require considerable expertise from the surgeon during the surgery and from the doctor who images the parathyroids prior to the surgery. Our recent paper in the November 2008 Endocrine Practice journal suggests that pre-operative high resolution neck ultrasound performed by an ultrasound-certified endocrinologist is the best imaging technique for locating an enlarged parathyroid (adenoma). In addition, we have found that close collaboration between an ultrasound-savy endocrinologist and a minimally invasive parathyroid surgeon is the key to cure. Two intra-operative procedures turn out to be very important in maximizing surgical success. The first is the use of intra-operative sestamibi scanning using a thin surgical probe. Technetium sestamibi is given intravenously 2 hours prior to surgery and during surgery the patient's neck is scanned carefully with the probe applied directly to skin and inserted in the surgical incision. In conjunction with the pre-operative ultrasound, the sestamibi scanning locates most enlarged parathyroids (~90%). However in some cases, the enlarged glands are too deep in the chest or neck for either technology to be effective. In these cases, the patient depends on the surgeon's skill in locating deep or hidden parathyroids. In order for the surgeon to recognize the existence of unimaged enlarged glands, he must first recognize that abnormal parathyroids are still present in the neck. This final realization is achieved by the utilization of the intra-operative parathyroid hormone blood test. After the removal of an enlarged parthyroid gland and before we declare any patient cured, we test the parathyroid hormone level in blood to make sure that it has fallen at least 50% from the pre-removal level. If such a fall has not occurred, we continue to look for other enlarged glands. Without the use of PTH testing in the operating room, we estimate that as many as 10-15% of patients could undergo removal of one enlarged parathyroid adenoma without being cured. Unfortunately, the lack of cure may take 3-6 months to be recognized, as the initial post-operative blood calcium levels may drop into the normal range, only to rise again later.
Our practical advice to patients can be summed up as follows:
(1) Make sure that you get your parathyroid adenoma(s) localized by a physician with special training in parathyroid localization (many radiology ultrasound technicians do not have this training).
(2) Make sure that your surgeon does at least 50 minimally invasive parathyroidectomies a year and that he or she works closely with an endocrinologist specializing in parathyroid problems. If the endocrinologist actually does parathyroid imaging with high resolution ultrasound this will save you the trouble of finding an experienced ultrasonographer elsewhere.
(3) Demand that your parathyroid surgeon use intra-operative sestamibi scanning as well as the blood parathyroid hormone assay to make sure that you are cured while you are on the operating table.
(4) Beware of any parathyroid surgeon who demands money up front for a telephone consultation. You have a right to meet your surgeon face-to-face before any money changes hands. You should not feel locked into using a surgeon because of a telephone consultation charge. Remember, there is a reason that no insuror will pay for up front telephone consultation,
(5) Beware of any surgeon who claims more than a 99% success rate, no matter how many patients he/she claims to cure every year. It is easy to claim that a patient is cured if you never see them again after the day of surgery. Many patients with 2 gland disease will initially show normalization of calcium levels after removal of one enlarged gland, only to have hypercalcemia recur 6-12 months later.
(6) If the claims you see on a parathyroid surgical website seem like hype, they probably are. Beware of unsubstantiated internet claims.
Please feel free to navigate to our website at http://www.ftles.com/ and review all our content critically. Good luck with your parathyroid surgery!!!
Monday, February 16, 2009
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