Parathyroid surgery

Hyperparathyroidism is often caused by a noncancerous growth called an adenoma. Parathyroid adenomas no longer sense calcium levels in the blood correctly and make too much PTH. As calcium levels get higher, symptoms and problems get worse. 

If you have hyperparathyroidism:

• Most of the time (80% to 85%), only one of the glands is the problem. 
• 5% to 10% of patients develop two or more adenomas. 
• Less commonly (5% to 10% of the time), all four glands get bigger. This is called hyperplasia. 
• A cancerous growth is rare and happens less than 1% of the time.

Parathyroid gland disease causes many problems. You might not have symptoms at first, but they often appear over time. Major symptoms include:

• Loss of bone density (osteopenia)
• Severe bone loss (osteoporosis)
• Bone breaks
• Kidney stones
• High blood pressure
• Gastric reflux
• Ulcers
• Bone pain
• Irregular, rapid heartbeats (rare)

Many patients don’t have any of these symptoms. Instead, they have more general symptoms, such as:

• Memory loss
• Low energy
• Aches and pains
• Muscle weakness in the legs
• Difficulty concentrating
• Feeling “out of sorts”
• Feeling tired, low or depressed

Often people assume these symptoms are related to getting old, being out of shape or feeling low. If you have any of these symptoms, talk with your doctor. Hyperparathyroidism can be found with a simple blood test to check calcium and PTH levels.

Patients with mild or severe parathyroid disease have similar symptoms. Both types of patients are likely to benefit from parathyroid surgery. 

Two types of imaging studies are often used together to find abnormal parathyroid glands: 

• An ultrasound of the lower neck uses sound waves to create pictures of the parathyroid glands. 
• A sestamibi scan identifies parathyroid glands that have moved outside of their normal place in the lower neck, which an ultrasound might miss. 

Another type of imaging called 4D-CT offers other benefits:

• It is highly sensitive and the most accurate imaging study for the parathyroid.
• It offers excellent detail for finding abnormal glands before surgery.
• It helps doctors tell parathyroid lesions apart from lymph nodes and thyroid nodules.
• It works well with the ultrasound and sestamibi imaging studies.

We offer 4D-CT and the sestamibi scan on the same machine and at one appointment. This better helps us find abnormal parathyroid glands.

There are two treatment options for hyperparathyroidism: 

• Watchful waiting, which means no treatment and regular monitoring
• Removing any glands that are causing problems by surgery

Surgery is the most common treatment and the only cure for hyperparathyroidism. A surgeon will remove only the parathyroid glands that are affected. Your body doesn’t need all four glands. After surgery, your PTH levels will start to return to normal.  

The surgical techniques we use generally have few complications and most patients do well with surgery. Studies show that both older and younger patients benefit from surgery. 

Minimally invasive parathyroid surgery is usually done as an outpatient (same-day) surgery. It involves making a small incision (cut) of about one to two inches on the front of the neck. 

An imaging study is done before surgery to find the abnormal gland and rule out the possibility of more than one gland being affected (multigland disease). 

This helps the surgeon make sure that the patient is a good candidate for minimally invasive surgery. It also helps the surgeon target a single gland to remove. Some surgeons use a radio-guided device to locate an adenoma during surgery. 

Parathyroid hormone levels are measured during and after surgery to make sure that all abnormal glands have been removed. Additional surgery is usually not needed. 

The parathyroid glands are sometimes difficult to find. Also, one out of five patients can have more than one parathyroid adenoma, which might not be found with imaging before surgery. 

If abnormal glands aren’t found before surgery, the surgeon will examine all four parathyroid glands during the operation. Any abnormal glands will be removed. A larger incision may be needed, but most patients are sent home the same day.

The cure rates of a minimally invasive parathyroidectomy and four-gland exploration are similar. The minimally invasive surgery offers the benefits of less scar tissue, shorter time in surgery, smaller incisions and a lower chance of problems. 

Other benefits of parathyroid surgery include: 

• About 70% of patients see an improvement in one or more of their symptoms. 
• Improvements in bone health and problems with kidney stones are well documented.
• Elderly patients may benefit greatly from parathyroid surgery and should be offered this option. 

Several large-scale studies done in Sweden and Denmark showed that patients with primary hyperthyroidism have significantly higher chances of dying from heart disease (stroke, heart attack, heart failure, and abnormal heart rhythms). 

The study also showed that, in some cases, parathyroid surgery returned patients to normal chances of getting heart disease. 

Similar studies done in the United States have not shown these results. Because of this, the question of whether primary hyperparathyroidism affects heart health has not been answered.

Thyroid nodules are lumps that form in the thyroid gland. Nodules are common and most are benign (noncancerous). But about 5% can be malignant (cancerous). There are several types of benign nodules: 

• A multinodular goiter is a thyroid with multiple nodules. 
• A uninodular goiter is made up of only one nodule. 

The word "goiter” means enlarged thyroid. It can be caused by one or more nodules or by the thyroid gland getting bigger in general. 

Nodules are often found during a physical exam. Some can be seen when the patient swallows or talks. Many are found by chance if imaging tests are done for other reasons. An ultrasound is the best way to see these nodules. Sometimes a CT scan or MRI scan is used. 

When nodules get bigger and look suspicious in an ultrasound, a biopsy (sample) should be taken using fine needle aspiration. If you have a nodule in your thyroid, talk with your doctor about the best course of action for you.

Many people develop nodules (lumps) in the thyroid gland. About 5% of thyroid nodules are a thyroid cancer. Most thyroid cancers have a very good prognosis. There are four main types of thyroid cancer.

Papillary thyroid carcinoma

Papillary thyroid carcinoma is the most common and accounts for about 80% of thyroid cancer cases. It usually grows slowly and is the cancer we have the most success with. 

It is more common in women and often affects people around age 40. It typically appears as a lump in the thyroid area or an enlarged lymph node in the neck. The best treatment is surgery. 

The type of surgery needed varies by patient. Surgeries include: 

• Total thyroidectomy (the whole gland is removed) 
• Near total thyroidectomy (almost the whole gland is removed)
• Thyroid lobectomy or hemithyroidectomy (the half of the thyroid with the cancer is removed)
• Sometimes removing the surrounding lymph nodes that may be affected

This type of cancer can spread to the lymph nodes, but this may not affect the patient’s long-term outlook. Radioactive iodine treatment may be done after surgery.  

When treatment is done, some patients are prescribed thyroid hormone under the guidance of an endocrinologist. The amount of thyroid hormone they need to take depends on the surgery and the final diagnosis.

Follicular thyroid carcinoma

Follicular thyroid carcinoma is the second most common type of thyroid cancer. Like papillary thyroid carcinoma, it usually appears as a lump in the thyroid area or an enlarged lymph node in the neck. 

Determining if the tumor is cancerous or not requires removing the tumor and examining it under a microscope. This cancer cannot be diagnosed with a fine-needle biopsy. 

Depending on how far the cancer has spread, it may not be necessary to remove both sides of the gland. If the cancer has spread significantly, removing the rest of the gland will be needed. This is often followed by radioactive iodine treatments.

Medullary thyroid carcinoma

Medullary thyroid carcinoma is linked to family history and accounts for less than 5% of cases. 

Anaplastic carcinoma

Anaplastic carcinoma is fast growing, aggressive and rare — less than 5% of thyroid cancer cases.

The most common reasons to do thyroid surgery are: 

• Thyroid cancer 
• Nodules that look suspicious and might be at risk for cancer 
• Nodules or goiters causing symptoms 
• Nodules that are visible on the outside of the neck
• Nodules larger than 4 cm (about the size of a walnut)
• Hyperthyroidism that is not managed well by medication or radioactive iodine therapy 

Surgery can be a thyroid lobectomy, also called a hemithyroidectomy, in which one side of the thyroid is removed. This is usually for small cancers in one nodule, tumors that are not obviously cancerous, larger nodules or nodules that can be seen. 

Surgery typically takes one to two hours. If cancer is found, some patients will need to go back to the operating room to have the remaining thyroid removed. 

Thyroid function is usually tested with thyroid stimulating hormone four to six weeks after a hemithyroidectomy. This is to make sure the remaining thyroid is making enough thyroid hormone.

A total thyroidectomy removes the entire thyroid. Surgery usually takes 1.5 to 3.5 hours. 

Most patients stay one night in the hospital after surgery. Calcium levels are checked often. If they are steady, you may be given calcium supplements to take at home. The dose will be reduced over a three-week period. 

You will also need to take thyroid hormone. Your doctor will give you a prescription. Your thyroid levels will checked after four to six weeks to make sure that your dosage is correct.

After surgery, most people have neck pain or stiffness and are given both opioid and non-opioid pain medicines such as Tylenol. Most patients also have a sore throat from the breathing tube used during surgery. But in general, the surgery is well tolerated.

The pain is usually highest the day after surgery but gets better after that. Some people may feel pain for longer. Plan on taking one to two weeks off from work. Patients should not lift more than 10 pounds for seven days. After that, there are few restrictions.