In this episode of PodMD, specialist breast, endocrine and general surgeon Dr George Liang will be discussing the topic of parathyroid disease, including what the disease is, how a patient would typically present, the warning signs a GP or their patient can look out for, the likelihood of recurrence, when to refer and more.
Please note this is a machine generated transcription and may contain some errors.
*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMD studio Dr George Liang.
Dr George Liang is a Specialist Breast, Endocrine and General Surgeon practicing at Cutting Edge Surgical Associates (CESA) in Castle Hill. CESA is a multidisciplinary clinic with other specialists in General, Colorectal, Head & Neck, Pancreatic & Hepatobiliary Surgery. He operates out of Norwest Private, Westmead Private and Strathfield Private Hospitals.
Dr Liang began his training at the University of Tasmania before undertaking specialty training in General, Breast and Endocrine Surgery through the Royal Australasian College of Surgeons, Breast Surgeons of Australia & New Zealand and Australia & New Zealand Endocrine Surgeons. George has over 12 years’ experience in his field having trained in Westmead, St George, Concord Hospitals in Sydney and Flinders Medical Centre in Adelaide.
Today, we’ll be discussing the topic of Parathyroid Disease.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.
George, thanks for talking with us on PodMD today.
George: Thank you for having me.
The topic of today’s discussion is Parathyroid Disease. George, Can you describe for our listeners what Parathyroid Disease is?
George: Well parathyroid disease itself is when the parathyroid itself is producing excessive amounts of our parathyroid hormone. And parathyroid disease itself is divided into 3 main types. So primary, secondary and tertiary hyperparathyroidism by the inner interests of today’s topic will concentrate on primary and secondary hyperparathyroidism itself.
Our primary hyperparathyroidism itself is usually found incidentally in patients with high calcium serum biochemistry, and these are usually found as a result of blood tests for any reasons at all, usually done at a GPs office, and this is usually further investigated with serum parathyroid hormone, and this comes back high as well, so primary hyperparathyroidism itself has high PTH and high calcium. Secondary hyperparathyroidism itself generally is something that afflicts people with very low vitamin D levels, but generally the majority of these patients are patients with end stage renal failures, so usually most of them known to a renal physician already.
They usually presents with low to normal calcium levels in their blood and very high PTH levels. Now tertiary hyperparathyroidism itself is something quite rare, but it is a progression from secondary hyperparathyroidism and usually patients presents with high calcium and high PTH. The majority of hyperparathyroidism itself is spontaneous, especially in primary hyperparathyroidism, but it can be associated with our prad-1 or P-R-A-D-1 gene mutation. Or men-1 which is multiple endocrine neoplasia one or 2A syndrome. These hight PTH can be caused by an adenoma that is autonomously releasing high amounts of parathyroid hormones or caused by parathyroid hyperplasia? And very, very rarely, in fact, I’ve never seen one by a malignant parathyroid gland.
How would a patient with a Parathyroid Disease typically present?
George: Well, generally our patients with primary hyperparathyroidism usually presents asymptomatically as I mentioned, usually an incidental finding through blood test and patients are found to have hypercalcemia and usually this will be followed by further investigations with parathyroid hormone levels. The symptoms of hypercalcemia and hight PTH generally includes GI symptoms of abdominal pain, nausea, vomiting, constipation and thirst. They also have produced urinary symptoms, including kidney stones and polyurea.
Then there is the CNS symptoms of depression, fatigue, confusion, memory loss, and insomnia. It also produces musculoskeletal symptoms, including joint pains, bone pain, which are all related to high PTH levels. So you can see that parathyroid disease itself causes a systemic symptoms, so it doesn’t just cause a problem in one area, but it causes a whole systemic problem for a patient.
And sometimes these are the symptoms that patients present with to a GP or to the physician for investigation. And as you can see, the symptoms itself are quite vague. They’re not obvious.
In terms of secondary hyperparathyroidism, generally, I do get most of these patients from the renal physicians rather than from the GP as these patients are looked after by the renal physicians for their end stage renal failure. And the majority of times that these patients actually need to have a parathyroidectomy performs or they’re referred for those is because they have severe osteoporosis or they’re having severe bone pain and joint pains associated with their very, very elevated PTH levels.
What are the risks of the condition?
George: Well the risk, as I mentioned earlier in the last question, was that it causes a whole myriad of systemic symptoms and these can bother patients. This can affect their quality of life. But mainly so because it causes hypercalcemia, so the calcium comes from somewhere, so it actually comes from the bone itself, so it can cause osteopenia and osteoporosis in the long term.
So obviously this doesn’t concern them in a short term, but if left untreated these can cause problems in later age. The next thing will be kidney stones. Sometimes this is the first clue that we have that the patient actually has hyperparathyroidism because they keep producing kidney stones and keep having to front up to hospitals for treatment for kidney stones.
And another group of patients are patients with depression. A lot of times these patients actually are investigated for organic causes and usually through the blood test that found to be hypercalcaemic. Of course, there are patients with joint pains that are always investigated with blood test and ultimately this leads to the discovery of primary hyperparathyroidism itself.
What are the treatment options?
George: Now in terms of treatment options wise. They are medical treatments and of course there are surgical treatments. In terms of medical treatments for primary and secondary hyperparathyroidism. They include the use of bisphosphonates. So you reduce the amount of calcium that’s released through the bone itself. This can also help as opposed to reduce risk of osteoporosis and osteopenia in the long term. And of course there can be treated with calcimimetics such as cinacalcet where you actually increased the sensitivity of the PTH receptors so that so that the parathyroid gland itself does not over produce parathyroid hormones.
Generally, the only option for cure is surgical resection. For primary hyperparathyroidism I generally approach this through a minimally invasive parathyroidectomy or what we call MIPS, M-I-P-S.
And this is performed through a small 2-centimetre incision on the skin on the ipsilateral side of the neck. It’s usually a transverse incision. So to be able to perform a MIPS, we would first need to, I guess number one is to make sure that we’ve got the correct diagnosis of primary hyperparathyroidism. Then we will need to perform imaging. So two kinds of imaging is required before a MIPS can be performed. The first one would be a structural or anatomical imaging. So that is done through an ultrasound to determine where the pathology or the disease parathyroid gland is.
This is followed by a functional scan. This is usually done through a [inaudible] scan. Or a SPECT CT scan. So ,combining these two imaging modality together you need to be able to have concordance, I guess, or the two images agreeing with each other that it is that parathyroid gland that is adenomatous, that is pathological and that’s the one that needs to be removed because as we all know, a normal human being has anywhere between 3 to 6 parathyroid glands. But generally, most people have 4 parathyroid glands. So you do need to know where the location is before you can undertake a minimally invasive parathyroidectomy.
In the event that these do not localise, we do have other tricks up our sleeve. So, the next imaging that will perform is a 4D CT scan. So, this is a very specialised scan done at radiology centres where they’ve done plenty because it is not a scam that’s done every day. You do need a radiologist that is experienced. It’s a specialised study and a contrast study. It is a timed study, so this is to aid us in looking for the parathyroid adenoma that is causing problems.
Sometimes all three comes back negative. And if all this is negative, then the next trick would be to perform a neck exploration where we look at all four quadrants of the thyroid gland itself, looking for the diseased parathyroid gland and remove only the one that needs to be removed.
In secondary hyperparathyroidism, generally patients have 4 gland neck exploration, meaning that we go straight for neck exploration. And we remove all the parathyroid glands and we re implant traditionally what we call half a parathyroid gland back into the deltoid muscle or into the sternocleidomastoid muscle, and these are usually marked. Even though we do say half, but sometimes the hyperplasia of the parathyroid gland in secondary hyperparathyroidism itself can be so massive that we really only reimplant what we think one normal sized prostate gland, parathyroid gland should look like.
The reason that we were implanted into the muscle that’s quite superficial generally and we mark them is so that in the event that these due enlarge again and causes hyperparathyroidism and symptoms in future again, we can remove all this very easily in another operation.
Have there been any developments in treatment in the last years or are there any in trials or development now?
George: Well, that’s a great question actually. So, in terms of the surgery itself, I don’t think there has been much changes in terms of how we approach the surgery itself. Surgery itself is still the gold standard in terms of treatment for hyperparathyroidism, especially in primary and secondary hyperparathyroidism. However, imaging modalities have improved so there are many papers out there where surgeons as well as physicians are now trying out different imaging modality to better localise a parathyroid adenoma. So, one of the I guess more successful imaging modality is through 18 F fluoro Colleen Pit CT scan to identify a parathyroid adenoma.
Studies have shown that this modality is very sensitive and very specific, and it’s less likely to miss parathyroid adenoma. However, this is not a modality that is commonly used in Australia still at the moment and generally with the modalities that we have and with their experienced radiologists and nuclear physician that we have. Our ability to localise parathyroid adenomas is still close to 90% generally.
And there are also now studies into localization scans for secondary hyperparathyroidism. To reduce the risk of it’s not picking up an ectopic parathyroid gland and hence not requiring the patient’s secondary hyperparathyroidism. So I think this is something that’s quite good because traditionally a passion with secondary hyperparathyroidism would end up just having a fore gland exploration upfront. Usually they don’t, we don’t recommend any further imaging prior, but I think imaging prime might be a good idea just to ensure that we don’t miss any ectopic parathyroid glands as the first operation is always the best operation.
Are there any warning signs a GP or their patient can look out for?
George: What number one is when we do find that patients do have hyperparathyroidism, sometimes we do need to treat their vitamin D deficiency, at times by treating the vitamin D deficiency itself. This would resolve the hyperparathyroidism itself. And this can be done through I suppose ensuring that we checked for the vitamin D levels in the serum itself. We also should be aware that there are many other causes that causes hypercalcemia, so one of them is obviously hyperparathyroidism.
About the other causes would include haematological conditions, so these would need to be ruled out. And other malignancies such as prostate cancer can also cause hypercalcemia, especially when they have it in their advanced and they have invaded into the sacrum itself. There are other syndromes that causes hypercalcemia, and these include lytic bone syndromes such as Padgett’s disease.
What is the likelihood of recurrence of the condition?
George: Well, for primary hyperparathyroidism, the risk of recurrence is anywhere between 5 to 10% over 10 years. In terms of secondary hyperparathyroidism, I guess the risk of recurrence would be due to the enlargement of the reimplanted parathyroid gland that we mentioned earlier or perhaps that there is an ectopic parathyroid gland that was not found during the initial operation and hence why I’ve mentioned that perhaps having imaging prior to expiration of the neck itself will be a good idea in the future.
When should a GP refer?
George: Well, for primary hyperparathyroidism itself, our patients should always be referred for management and treatment. Especially when they are fit and well enough for general anaesthesia. Hyperparathyroidism itself, as I mentioned, causes a myriad of systemic disease which can be cured quite easily through a small operation such as MIPS. I’ve got many examples of patients that has presented with primary hyperparathyroidism with joint pains and bone pain.
Quite surprisingly a lot of these patient’s pain actually resolve are pretty much a few hours after the operation when the PTH levels come down rapidly and this is always very satisfying for us surgeons to be able to not just treat the hyperparathyroidism but also treat their symptoms which have been impairing them perhaps for many, many years.
And a lot of patients are always mentions that their mental fogging almost disappears after the operation. For secondary hyperparathyroidism, these are usually referred on to us by the renal physicians after patients are usually in the cohort of the end stage renal failure patients at their own dialysis and these patients are generally only referred if they can’t be medically managed.
Or perhaps they have severe symptoms of joint pains and bone pains.
What role does the GP play in the treatment of the condition?
George: Well, GP a big role this. Hyperparathyroidism itself is a clinical diagnosis, and it’s a diagnosis that’s usually picked up instantly on the blood test itself. So, a GPU plays a big part to ensure that we continue to determine the cause of hypercalcemia. Once this once the diagnosis is confirmed, then the GP should organise some imaging, including an ultrasound of the neck itself.
And of course, whilst we are investigating the neck, we should also investigate to make sure that there are no other lesions in the thyroid gland that needs to be investigated or treated. And of course, serum TSH levels as well as vitamin D levels should always be performed prior to referral.
We should also always be vigilant about the organic cause of depression. And one of them is hyperparathyroidism. So always, always make sure that you perform a serum calcium level as well in managing a patient with depression to ensure that there’s no other organic causes.
For patients with recurrent renal stones with severe constipation’s and nonspecific abdominal pains they should always have our serum calcium levels to ensure that they don’t have hyperparathyroidism that’s causing or driving all these problems.
And of course ,we should always ensure that we check the patients renal functions as well to ensure that they don’t have an acute or chronic kidney injury.
Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on Fibroadenoma and phyllodes tumour
George: Primary and secondary hyperparathyroidism itself causes a myriad of systemic owners I’ve as I’ve mentioned earlier and of course it reduces the quality of life of patients and these symptoms are not only just driven by hypercalcemia but also by the high PTH level itself.
#2, the best treatment option itself currently is still a parathyroidectomy, be itthrough neck exploration or MIPS. For the patients that are unable to have surgical treatment, they can be referred to an endocrinologist for a medical treatment, but these are generally not the preferred options.
#3. We should always we ensure that we look out for other causes of hypercalcemia, including haematological causes and malignancy. In fact, the most common cause of hypercalcemia in hospital setting is malignancy, and it can be malignancy of any sorts, including prostate cancers, bowel cancers. Or any malignancy that causes metastases to bone, including breast cancer.
Thanks for your time and the insights you’ve provided.
George: Thank you.