Parathyroid Disease (Hyperparathyroidism)
What is Hyperparathyroidism and what is a parathyroid tumor?
Parathyroid hormone (PTH) regulates calcium, phosphorus, and magnesium levels within the blood and bone. The four parathyroid glands, which are located in the neck around your windpipe, secrete this hormone when calcium in the blood stream is low – PTH then tells your body to absorb more calcium from your gut, excrete less calcium from the kidneys, and release calcium stores from bones.
Hyperparathyroidism occurs when there is an enlargement or tumor of one or more of the parathyroid glands, which results in overproduction of PTH. There are three main types of hyperparathyroidism:
- Primary: The parathyroid glands independently over-produce PTH regardless of calcium level in the blood.
- Secondary: The parathyroid glands over-produce PTH in response to chronically low calcium levels in the blood. This can occur in patients with kidney failure, vitamin D deficiency, and diseases causing malabsorption of calcium from the gut.
- Tertiary: The parathyroid glands independently over-produce PTH in patients with secondary hyperparathyroidism from kidney failure who then undergo kidney transplantation. In these patients, the transplanted kidney normalizes calcium levels in the blood, but the parathyroid glands continue to over-produce PTH because they have been stimulated to do so for a long time.
There is a wide range of disease severity in hyperparathyroidism – patients with more severe disease may experience kidney stones, bone pain, fractures, and marked neurocognitive disturbances. On the other hand, patients with mild disease may have more subtle symptoms that are difficult to attribute directly to hyperparathyroidism, such as fatigue, muscle weakness, irritability, memory loss, constipation, excessive urination, or heartburn. Prolonged hyperparathyroidism can lead to significant health problems such as osteoporosis, cardiovascular disease, stroke, and kidney damage.
At Weill Cornell Medicine, we use a multidisciplinary approach to accurately diagnose hyperparathyroidism with comprehensive bloodwork and imaging studies, which include neck ultrasound and 4D-Computer Tomography Parathyroid Imaging performed by expert radiologist. These studies can localize which parathyroid gland(s) is the culprit causing the overproduction of PTH, and thus help guide our surgical approach.
For primary hyperparathyroidism, surgery to remove the affected gland(s) is offered to patients with severe disease and symptoms that are directly attributable to hyperparathyroidism. However, the decision to offer surgery for patients with subtle symptoms, or without symptoms, is more complex. Since about 25% of patients with mild disease will eventually progress to having more severe disease, we offer surgery to patients based on individualized criteria and current guidelines.
For secondary hyperparathyroidism, most patients can be managed with medications in conjunction with a transplant nephrologist. Surgery can be considered in patients with severe disease who do not respond well to medical management.
For tertiary hyperparathyroidism, patients with mild disease can be medically managed; however, those with worsening disease, notable symptoms, or severe electrolyte derangements that do not improve with medications are candidates for surgery. Studies have shown early intervention improves kidney transplant survival.
Surgery for hyperparathyroidism has been associated with improved bone mineral density (preventing osteoporosis), preventing kidney insufficiency, and reduced long-term cardiovascular risk. Additionally, several studies suggest that neurocognitive symptoms may resolve after surgery, thus also improving quality of life. Your endocrine surgeon will discuss if surgery is the right option for you.
Our goal is to cure primary hyperparathyroidism using a minimally invasive surgical approach to remove the diseased parathyroid glands guided by pre-operative imaging localization studies. The operation can be performed under local or general anesthesia through a small incision in your neck using intraoperative PTH monitoring. Since parathyroid hormone in the bloodstream degrades within minutes on its own, we measure its level at the beginning of surgery and then again 10 minutes after the affected parathyroid gland has been removed. If the PTH level decreases to a normal level, then we are confident we have removed the diseased gland, without the need to search for additional affected glands. If the PTH level does not decrease, we then need to pursue looking for additional diseased glands.
The risks of parathyroid surgery include bleeding, nerve injury that could affect your vocal cords and thus the quality of your voice, and damage to the remaining parathyroid glands resulting in low calcium levels in the bloodstream. Our surgeons, due to their expertise and large experience, have minimized these risks to some of the lowest in the country. In fact, we typically will evaluate your vocal cords before and after surgery to assess for any laryngeal dysfunction using fiberoptic laryngoscopy. During this quick bedside procedure, your surgeon will use a narrow flexible telescope to look in the back of your throat to evaluate your vocal cords. Additionally, during the parathyroid operation itself, our surgeons may use nerve-monitoring technology, which helps identify and assess the integrity of your vocal cord nerve in real-time.
After parathyroid surgery, most patients will be able to go home the same day after a brief observation period. Recovery is very quick and the procedure causes little discomfort. Patients usually resume normal activity the next day and we advise you to return to work when you feel ready. Your surgeon will discuss in detail with you the expected recovery period.
Since hyperparathyroidism can recur in a small proportion of people, all patients are enrolled in our post-operative active surveillance program. This will entail serial bloodwork that our staff will monitor. If a patient is noted to have an increasing PTH or calcium on routine bloodwork, we will investigate for recurrence with parathyroid imaging studies.
At the Weill Cornell Endocrine Oncology program, we are dedicated to a patient-centered multidisciplinary approach to provide you with the most up-to-date treatment options and access to clinical trials for parathyroid disease.