Gibson talk

Name: Gibson talk
Uploaded: 2023-08-03T14:37:38.3533333Z
Duration: 42 min 48 s

August 03, 2023

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ID: 10162
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00:00Good afternoon everyone.
00:02My name is Courtney Gibson and I'm an end
00:06concern here at Yale New Haven Hospital.
00:09So I'd like to thank the hyperparathyroidism
00:12support and information group.
00:14I'm headed by Rochelle for inviting me to
00:17going to give a talk on you know general
00:20aspects of primary hyperparathyroidism
00:21and more specifically to answer the
00:24many thoughtful question that you
00:26questions that you all have sent in.
00:28So I'm hoping to just give a brief
00:31overview that I hope answer some
00:33questions just about the disease
00:35process itself and then we'll get
00:37into some of the questions that
00:38you have specifically asked.
00:39So I'm going to go ahead and share
00:42my screen here if I can do so.
00:44Let's see here
00:50Okay. All right.
00:51So hopefully you all can see this.
00:54So again, my name is Courtney Gibson and
00:56I'm Associate Professor of Surgery here.
00:59I'm an endocrine surgeon here at Yale
01:01and I've been here for the past 10 years.
01:03And today I just want to talk
01:05about parathyroid disease.
01:06What is it and how do we treat it?
01:08I have no disclosures.
01:10So first and foremost,
01:12primary hyperparathyroidism,
01:13which is the, you know,
01:15the essence of our talk,
01:16is the most common endocrine
01:18disorder of all endocrine disorders
01:20occurring in approximately one in 800
01:22people in the United States alone.
01:24And that number increases to one
01:26in 250 women over the age of 60.
01:29Although it can happen to any
01:31gender at any age,
01:32the male to female ratio is pretty
01:35even under the age of 40 and increases
01:37to about 4:00 to 1:00 on the female
01:39side once you're over age 60.
01:41There's approximately 100,000
01:43cases diagnosed annually and
01:45that's diagnosed cases.
01:47And we do know that there is a common
01:51underdiagnosis and misdiagnosis
01:53that happens nationally and
01:55internationally which leads to some
01:57significant problems for patients.
02:02So in general, you know what is
02:04primary hyperparathyroidism.
02:05It is over secretion of parathyroid
02:08hormone by one or more parathyroid glands.
02:11So under normal conditions, whatever
02:12we eat or drink that has calcium in it,
02:14our body stores the the calcium that we
02:17need in our bones in our skeletal system.
02:20And the excess amount largely
02:22gets excreted in the urine.
02:24And our when our parathyroid
02:25glands are functioning normally,
02:26this process happens pretty smoothly.
02:28And that's why many of us,
02:30many patients,
02:30don't even know that they're
02:32that parathyroid glands exist.
02:34But somehow for unknown reasons,
02:36one or more of these glands can
02:38become autonomously functioning,
02:39meaning they don't follow the
02:42normal process of, you know,
02:44calcium regulation and they
02:46become overactive independently.
02:47We do know that there's an association
02:49between high doses of radiation exposure
02:51in childhood and the onset of parent
02:53thyroid disease later on in life.
02:55But for the majority of these cases
02:57that that history doesn't exist.
02:59It's just a spontaneous event that happens
03:01in an individual and when that happens,
03:03there's an an excess hormone of
03:05parathyroid hormone that gets secreted
03:07and it tells the body to do things
03:10that normally it shouldn't be doing.
03:12So for example,
03:13the kidneys are told to hold onto too
03:15much calcium and so that's why patients
03:17with primary hyperparathyroidism
03:18are prone to develop kidney stones.
03:21Along with that,
03:22they tend to have polyuria or frequent
03:24urination because the kidneys are
03:26trying to get rid of the excess
03:28calcium that is coming into the
03:30collecting system and that can lead to,
03:32you know,
03:33excessive thirst or constant
03:34feelings of dehydration.
03:36The intestinal system also changes
03:39when there's parathyroid hormone,
03:41excess in the body.
03:42And instead of getting revved
03:44up like the kidneys do,
03:45the intestines tend to slow down,
03:47their motility slows down and there's
03:50decreased peristalsis or movement
03:52of intraluminal fluids and and
03:54solids within the intestinal system
03:57and that can lead to Constipation.
03:59Constipation is something that can
04:00happen to any of us at any given moment.
04:03But when it's pretty consistent
04:05or frequent Constipation in the
04:07setting of hyperparathyrosism,
04:09there definitely can be a
04:10direct relationship there,
04:13the bones, the skeletal system.
04:15So this is as I mentioned earlier,
04:17this is where most of our calcium is
04:19stored under normal conditions and in
04:21the setting of parathyroid disease.
04:23This excess hormonal signal is telling
04:25the bones that that there is a need to
04:27release its calcium from the skeletal
04:29system and it's the release of calcium
04:32from the bones that leads to the rise in
04:34serum calcium or calcium levels in the blood.
04:37But at the same time,
04:38it is also demineralizing the bones.
04:40And so over time, patients can develop
04:43bone disease such as osteoporosis,
04:45which is the initial demineralization
04:47of bones that is reversible.
04:49But if gone unchecked and uncorrected,
04:51that could lead to osteoporosis,
04:52which is irreversible bone
04:54loss in either case.
04:56Parathyroid treatment of the
04:58parathyroid disease is important.
05:01In the case of Osteopenia,
05:02that reversible bone loss can be
05:04recovered completely in many cases,
05:06whereas in osteoporosis,
05:07those patients will go on to
05:09likely need some sort of medical
05:11treatment for their osteoporosis.
05:13However,
05:13the bone density can improve with
05:16successful parathyroid treatment,
05:17treatment of hyperparathyroidism.
05:19And then lastly,
05:20there's a phenomenon or condition called
05:23neurocognitive dysfunction that is
05:24associated with parathyroid disease.
05:26That is very common syndrome or cluster
05:29of symptoms that can include memory loss,
05:33mental fogginess,
05:34poor concentration,
05:35fatigue out of proportion to
05:37what one does every day and even
05:40feelings of new onset or worsening
05:42anxiety or depression that in the
05:44setting of hyperparathyroidism we
05:47call neurocognitive dysfunction.
05:49So how do we diagnose or work
05:52up this condition?
05:53So what typically happens in the
05:55classical setting is a patient is
05:56found to have high calcium in their
05:58blood either on routine blood work
06:00or they present with some symptoms.
06:01And that leads to, you know,
06:03an investigation as to why
06:04they're having the,
06:05say for example,
06:07severe fatigue or recurrent kidney stones.
06:09And those patients are found to
06:11have an elevated calcium level.
06:12And then ultimately hopefully their
06:14parathyroid hormone levels get checked
06:16and that's also found to be elevated.
06:18And that's what makes us kind
06:20of lead to that diagnosis of
06:23primary hyperparathyroidism.
06:24So the work up of primary
06:27hyperparathyroidism should start
06:28with biochemical work up after a
06:30patient presents with symptoms of
06:33hyperparathyroidism or they are found
06:35incidentally to have a high calcium level.
06:38And that work up should include,
06:39yes, the serum calcium,
06:42an intact PTH level.
06:44But other important biochemistry that
06:47should be looked into is serum phosphate,
06:50kidney function,
06:52BU and creatinine levels and
06:54vitamin D levels.
06:55Some additional testing that
06:57may be done as a 24 hour urinary
06:59calcium as well as a PTHRP and
07:01that's important we think of the
07:03when we were thinking about the
07:07differential of hypercalcemia.
07:08So the spectrum of primary
07:11hyperparathyroidism is,
07:12you know,
07:13there's classical primary hyperparathyroidism
07:15where the calcium is elevated and
07:18the parathyroid hormone is elevated.
07:20And under normal conditions,
07:21those two parameters should be
07:23working in opposite directions.
07:25And then there's subtypes
07:26where the calcium may be in
07:27the normal range,
07:28but the parathyroid hormone is
07:30persistently elevated and there's
07:31no other reason to explain that
07:33elevation in the parathyroid hormone.
07:35There's also a normal hormonal
07:38primary hyperparathyroidism where
07:39the calcium is significantly elevated,
07:42but the parathyroid hormone levels
07:44remain quote UN quote within the normal
07:46range and we call that an inappropriate
07:49secretion of a type of a parathyroid
07:51hormone in a setting of hypercalcemia.
07:54So for example,
07:54if a person has a calcium of 11 out
07:57of the range of normal under normal
07:59conditions that the parathyroid
08:00glands are functioning normally,
08:01we would expect the parathyroid
08:02hormone level to be suppressed.
08:04So the normal range of PTH
08:05is between 10 and 70.
08:07We would expect that patient have
08:08a PTH somewhere around 10 or 20.
08:10So if a patient has a calcium that's at
08:12the upper end of normal or above normal,
08:14say you know 10.511 or higher
08:17and their PTH is 60,
08:19although that technically
08:20is within the normal range,
08:21that's an inappropriate amount of
08:23parathyroid hormone being secreted
08:25given the high calcium level.
08:26And so that qualifies or as as
08:30primary hyperparathyroidism.
08:31And then you know the most,
08:33the more difficult cases to diagnose
08:35would be the normal calcemic primary
08:37hyperpara and the biochemically normal
08:39primary hyperpara where both the
08:41calcium and the PTH levels are normal.
08:43But patients have symptomatology
08:45consistent with primary hyperpara
08:47thyroidism that cannot be explained
08:50by other disease processes.
08:51So in general,
08:52the key to the diagnosis is
08:54a nonsuppressive relationship
08:55between calcium and PTH.
08:57But there are subtypes that do
08:59exist that we'll talk about when
09:00we answer some of the questions.
09:02It's important to note that
09:03the degree of symptoms is not,
09:05does not depend on calcium levels.
09:07So sometimes patients are told that,
09:09you know,
09:10their calcium levels are mildly elevated.
09:11But it's nothing to worry about because,
09:13you know,
09:14patients seemingly should feel fine.
09:15And oftentimes, primary care doctors may,
09:19you know,
09:19overlook a serum calcium that's
09:21elevated because in the grand scheme of
09:23all the things that they're looking into,
09:24a mildly elevated serum calcium
09:27seems harmless.
09:28But we definitely know from
09:29experience and in the literature
09:31that there are patients who are very
09:33symptomatic even with minor elevations
09:34in their serum calcium levels.
09:35And there are those who have
09:37very high serum calcium levels
09:38that don't necessarily present
09:39with significant symptoms.
09:43Vitamin D levels are important to check,
09:46as I mentioned, because you can
09:49have a condition called secondary
09:51hyperparathyroidism where the
09:52parathyroid glands become overactive
09:54because there's a vitamin D deficient
09:56deficiency and that's an appropriate
09:59overactivity of the parathyroid glands.
10:01Once the vitamin D is corrected,
10:02if that was the sole source
10:04of the overactivity,
10:05then we would expect the
10:06parathyroid hormone to normalize.
10:07But there are some cases where patients
10:10have concomitant vitamin D deficiency
10:12and primary hyperparathyroidism and
10:14particularly in the United States where
10:16we tend to avoid the sun, you know,
10:19for fear of developing skin cancer.
10:21Sunlight exposure is important for
10:23conversion of vitamin D into the active
10:26form that we need as human beings.
10:28So many of us here in the United
10:29States are vitamin D deficient
10:31whether we know it or not and that
10:32can lead to a mild elevation in
10:34parathyroid hormone secretion.
10:36But in patients who have that condition
10:40along with primary hyperparathyroidism,
10:41once you correct the vitamin D deficiency,
10:43they still have persistent elevated
10:45PTH levels consistent with
10:47primary hyperparathyroidism.
10:49It's important to note,
10:51to rule that process in or out the vitamin
10:54D has to be corrected and it takes
10:56some time to correct vitamin D levels.
10:58Sometimes it can take 8-8 weeks or
11:01longer to get patients to normal
11:03vitamin D levels on supplementation
11:05and so patients need to be patient
11:09in order to elucidate whether or not
11:11there is an indeed a primary problem
11:13with the parathyroid function or is it
11:15solely due to the vitamin D deficiency.
11:20So in general, there are
11:25guidelines for indications for surgery
11:27that you know that an international
11:30workshop of parathyroid experts come
11:33together every five to seven years ago,
11:35five or seven years,
11:36and come up with these guidelines.
11:38And so these are just guidelines,
11:39they're not set in stone.
11:41So in general age under 50 years
11:43was a guideline serum calcium
11:45greater than 1 gram per deciliter,
11:47bone mineral density,
11:48you know consistent with osteoporosis or a
11:52declining renal function as listed here.
11:54Now these are guidelines for asymptomatic
11:57patients with primary hyperparathyroidism.
11:59Any patient who is symptomatic
12:01should seek out surgical referral
12:03or should be referred for surgical
12:05management of their disease process.
12:07And even the asymptomatic guidelines that
12:09you know the guidelines are changing,
12:11everchanging.
12:12I do think we'll get to a point
12:14where age will be off the table
12:15because we certainly don't exclude
12:17patients based on age of whether or
12:18not they should receive surgery to
12:20treat their parent thyroid disease.
12:22And in fact most patients are
12:23over the age of 50.
12:25So the age under 50 doesn't make much sense.
12:28So I do think that is a guideline
12:30that will fall off in due time.
12:34So localization studies are helpful when
12:36we want to you do a targeted approach
12:39and minimize the amount of surgery,
12:41the amount of deception and
12:42anesthesia needed.
12:43But again,
12:44localizations,
12:45localization studies are after you have
12:48confirmed that the patient has primary
12:51hyperparathyroidism and to confirm
12:54that the patient wants to have surgery.
12:56So, you know, in the absence of that,
12:58localization studies are unnecessary and
12:59sometimes things are done out of order.
13:02A patient gets an ultrasound done
13:03before we even have a biochemical
13:05confirmation of parathyroid disease.
13:07And although most parathyroid glands
13:08when they're normal in size and shape,
13:10they're not visualized on imaging.
13:12Some can be seen by,
13:13you know,
13:14a very astute radiologist may pick up a
13:16parathyroid gland on an imaging study
13:18and that can be a totally normal gland.
13:20It does not mean that gland
13:22needs to come out.
13:22So we have to take a step back
13:24and first of all confirm that that
13:27patient indeed has biochemically
13:29proven primary hyperparathyroidism.
13:31But in terms of the localization studies
13:33that we use in trying to identify
13:36preoperatively abnormal parathyroid tissue,
13:38here are some there,
13:40there are many and the institution
13:42specific here at our center,
13:44we typically use an ultrasound in a 4D CT.
13:47The ultrasound is used primarily to look
13:49at the thyroid gland because in up to
13:5120 to 30% of cases of parathyroid disease,
13:53there may be a thyroid problem
13:55like a thyroid nodule that needs
13:56to be investigated further and
13:58maybe even needs to be recepted.
14:00So if a patient presents with
14:01a thyroid nodule that needs
14:03to undergo surgical resection,
14:05we'd prefer to do that within one
14:07surgical procedure instead of,
14:08you know having to do 2 separate ones.
14:09So that is the main utility of of of
14:12doing an ultrasound preoperatively.
14:15In some cases,
14:16a large abnormal parathyroid gland
14:17can be
14:18detected on ultrasound and that's
14:20also helpful and beneficial.
14:21But if it's not, that doesn't mean
14:23the patient doesn't have disease
14:24because I refer you back to step one,
14:26biochemically prove that
14:27the patient has disease.
14:29And then the next test that we use here is a
14:33parathyroid specific CAT scan
14:35called a 4G CT And we've compared
14:37that with our cestomes that we've
14:39done here and the sensitivity and
14:41specificity of the four DCT is far
14:43superior to that of the cestomes.
14:45So our secondary study that more
14:47specifically identifies and targets
14:49abnormal parathyroid tissue is the
14:514D CT and that's the combination
14:53that we use here when we're
14:54trying to plan for surgery.
14:59Intraoperative measurement of PTH is
15:00crucial if you have that available to you.
15:03So just like the diagnosis of primary
15:06hyperparathyroidism is based on biochemistry,
15:08cure should be based on biochemistry,
15:10and it is based on biochemistry.
15:12So you are not considered to be cured
15:14of your parathyroid disease even after
15:16surgery until you're six months down
15:18the line and your calcium vitamin DPTH
15:20levels are checked again and they're
15:22found to be in the normal range.
15:24Now a nice surrogate is intraoperatively
15:26if you can get normalization of the
15:28parathyroid hormone by the end of
15:30surgery then the chance of cure is
15:33pretty significant, greater than 95%.
15:34Meaning if you get the parathyroid hormone
15:37levels normalize at the time of surgery,
15:3995% of those patients will go on to have
15:42curative disease cure of disease confirmed.
15:44Six months down the line,
15:47the half life of parathyroid
15:48hormone is about four minutes.
15:50So every, you know,
15:513 1/2 to 5 minutes the PTH and in a person's
15:55system is degrading by roughly 50%.
15:58And this is very helpful because we
16:01can get real time information on how
16:04quickly the parathyroid function is
16:06degrading at the time of surgery.
16:08And then there's different criteria
16:10that are used to have listed here
16:11the Miami criteria and that says
16:13that there should be a 50% decrease
16:1510 minutes after you have surgical
16:18resection that should be consistent
16:20with cure of disease
16:24at the time of surgery. Now I don't
16:27specifically follow that criteria.
16:28I do believe that there should be at
16:30least a 50% drop in about 10 to 15
16:32minutes after you feel like you resected
16:35all the disease parathyroid tissue.
16:37But in addition to that,
16:38I want to see that drop remain
16:39in the normal range,
16:41you know for another two or three samples.
16:43And I do that because some patients
16:44come with a very elevated parathyroid
16:46hormone at the time of surgery.
16:48So they can have a PTH that's over 200
16:50and normal range being between 10 and 70.
16:53So let's say 15 minutes after I resected
16:55a big and large parathyroid gland,
16:57the the PTH drops from 200 to 100.
17:00That's encouraging.
17:01But that 100 is still elevated and I don't
17:04want to end my case with an elevated PTH.
17:06So I want to see that that is going
17:08to continue to drop down and get down
17:09into the normal ranges and then level
17:11off and then and then low normal
17:12range somewhere around 30 or so.
17:15So that's why I always send extra
17:17samples or have the anesthesia,
17:18I'll just send a few extra samples once
17:20we get a normal value to make sure
17:22that it's not starting to rise again,
17:23which would suggest that there's
17:26more disease present than what
17:28the preoperative imaging shows.
17:29And that happens sometimes.
17:33We have,
17:35I'm sorry, so the differentiation of
17:38hyperparathyroidism, just briefly,
17:39you know, the difference between primary,
17:41secondary and tertiary has to do with
17:44what is the insult that is causing
17:47the parathyroid to become overactive.
17:49So in primary hyperparathyroidism,
17:51there is no insult.
17:52These glands start autonomously
17:54functioning and there's not a secondary
17:56cause that's making them do so.
17:57So the primary problem is with
17:59the parathyroid function of
18:00parathyroid tissue itself.
18:02And in those cases,
18:03in the classical case,
18:04serum calcium is elevated,
18:06parathyroid hormone is elevated and
18:08vitamin D should be normal or elevated.
18:10In secondary hyperparathyroidism.
18:11There's a secondary cause as to
18:14why the parathyroid glands are
18:16over functioning and that secondary
18:18cause can be a vitamin D deficiency
18:20like we talked about earlier or
18:22it can be kidney dysfunction like
18:23end stage renal disease.
18:25And so that's where the other levels
18:27like checking the creatinine and
18:29phosphate levels are important.
18:30So in secondary Hyperpara patients
18:34have overactivity of their parathyroid
18:36glands because they have high serum
18:38phosphate levels and low vitamin D
18:40levels because of their kidney failure.
18:43And the parathyroid glands don't
18:44know that the kidneys have failed.
18:45So they are overactive and revved
18:47up trying to get the kidneys to
18:49release the excess phosphorus,
18:50which cannot happen in the setting
18:52of kidney failure.
18:53And then tertiary hyperparathyroidism
18:56happens after prolonged secondary
18:58hyperparathyroidism that has
18:59been left untreated.
19:00And so this happens usually in two settings,
19:03either a patient who has instage renal
19:06disease and secondary hyperparathyroidism
19:08that just goes on untreated for many,
19:11many years.
19:12And so their calcium ultimately
19:13begins to rise as if they are
19:16someone with primary hyperpara.
19:17That's one case.
19:18The other case is a patient who
19:20successfully got a kidney transplant when
19:23they had secondary hyperparathyroidism.
19:24And despite now having
19:26normal kidney function,
19:27those glands have been autonomously
19:29functioning for quite some time and they
19:31have not fully gone back to normal.
19:33And so that is tertiary hyperpara
19:35and those patients usually go
19:37on to surgical treatment of
19:38their hyperparathyroidism.
19:39But that's beyond the scope of
19:41what we're going to discuss today.
19:43So we can skip over these
19:47Okay. So basically talked about
19:49secondary inter sharing. All right.
19:52So I am going to stop sharing now and
19:56let's see if I can get to the important
20:02questions that you guys have asked.
20:06Okay, I'm going to pull them up here.
20:10All right. And so for the remainder
20:12of our time here, I'm just going
20:13to get through as many as I can.
20:16Some of them are repetitive questions,
20:19so that's good. That means there's,
20:20you know, high interest in that question.
20:22Hopefully I can get to those.
20:23So let's see.
20:24So the first question is some
20:26surgeons hesitate to operate on
20:28patients presenting with normal
20:29calcemic hyperparathyroidism because
20:30they claim that the surgery will
20:33not benefit them in the long run.
20:34What would be the criteria for you
20:36to be doubtful about accepting a
20:38normal calcemic patient for surgery?
20:40This is a very good question and
20:43it's you know normal calcemic
20:45primary hyperparathyroidism is a
20:47very controversial topic and it's
20:49not so much controversial in this
20:51in those of us who are what have a
20:53lot of experience in dealing with
20:55primary hyperparathyroidism and
20:56the surgical management of them.
20:59So we are not unclear about the diagnosis.
21:01We definitely believe that this entity
21:03exists where you can have normal
21:05calceming primary hyperparathyroidism.
21:07The controversy or the confusion
21:09lies in what to do about that.
21:11So in classical case primary
21:15hyperparathyroidism,
21:16most patients have single gland disease.
21:18You remove that one gland,
21:20the problem is solved and the remaining
21:22three healthy glands will eventually
21:23wake up and function at a normal level.
21:25But even in the setting where you have
21:28primary hyperparathyroidism and all
21:29four glands are disease and we have
21:31to perform what's called a subtotal
21:33parathyroid resection where we remove
21:35the majority of your parathyroid tissue.
21:37We are comfortable as surgeons and
21:39confident that even removing the bulk
21:41of that tissue we're not going to leave
21:43give you permanently hypocalcemic
21:44and we have a a bigger window of
21:46opportunity to allow the calcium to drop.
21:48So most of those patients
21:50are already hypercalcemic.
21:52So their calcium levels are well over 10,
21:54sometimes over 11 and 12.
21:56And after we remove you know that
21:58that disease parathyroid tissue that
21:59serum calcium is going to drop,
22:01it's going to ultimately land
22:02in the normal level,
22:03but sometimes it'll overshoot
22:05and it'll be in the low,
22:06you know it'll be low and not normal.
22:08And those patients can present
22:10with pretty significant symptoms
22:12of muscle aches and pains,
22:14numbness and tingling and they will need
22:16some calcium supplementation for a time.
22:18So we are understanding of that as
22:23as parathyroid doctors and surgeons
22:27and we properly prepare our patients
22:30to experience that and let them
22:32know that that those symptoms should
22:33persist for days maybe you know a
22:35week or two but should subside.
22:37When we're talking about normal calcium,
22:38the primary hyperparathyroidism,
22:39the problem is we don't have that
22:42much of A window of opportunity.
22:43Those patients already have calcium
22:45that are that's normal.
22:47So we're talking about a calcium that is,
22:48you know, 99.5 sometimes even you know,
22:51high eights. And we and also many
22:54of those patients need a subtotal
22:57resection because there's a higher
22:58incidence of multigland hyperplasia
23:00where all four glands are diseased.
23:02And so taking out one is not going to
23:04solve the problem in patients who have
23:06normal calcemic primary hyperparathyrosism.
23:08So not only are we having to perform
23:12a potential subtotal resection
23:13in these patients,
23:14we have a lower window at of where
23:17that calcium can safely drop.
23:19So you're starting out already
23:20normal and not high and now you're
23:21definitely going to be low for a
23:23while and that can be a long while,
23:25prolonged while.
23:25And so those patients can end up pretty
23:28symptomatic and and initially feel a
23:30lot worse than they did just having the
23:32normal calcium and primary Hyperpara.
23:34So for those reasons you know individual
23:37surgeons have come up with different
23:40criteria that they need met in order
23:42to offer surgery to those patients
23:44and it's really in an effort to do
23:46good and not harm in those patients.
23:49We don't have enough data yet to
23:53say consistently which patients with
23:55normal calcemic hyperparathyroidism
23:56are going to benefit from surgery.
23:58Now me personally I like to have
24:00some hard evidence that the patients
24:02are have significant symptoms of
24:04parathyroid disease and by that
24:05I mean evidence of bone disease.
24:07So osteopenia,
24:08osteoporosis,
24:08evidence of kidney disease like kidney
24:11stones that have been clinically
24:13significant or at least they are
24:16detectable on a kidney ultrasound.
24:18So that's those are things that
24:19we know treating the parathyroid
24:21disease will treat those symptoms
24:23or improve those symptoms.
24:25So we can,
24:26we definitely know that treating parathyroid
24:28disease and curing it improves bone health.
24:30It decreases your risk of
24:32developing kidney stones.
24:33What's less tangible or for lack
24:35of a better term or harder to show
24:39is the neurocognitive symptoms.
24:41So you know,
24:42neurocognitive symptoms such as fatigue,
24:45memory loss, anxiety,
24:47depression is often multifactorial.
24:50And while parathyroid disease definitely
24:52can can significantly contribute to that,
24:55it's often not the sole source of
24:57those neurocognitive symptoms.
24:58And so if we, you know,
24:59offer surgery to patients with normal
25:02calcemic primary hyperparathyroidism
25:04who only have the neurocognitive
25:06symptoms and then we end up having
25:09to do something like a subtotal
25:10resection in that patient.
25:12They may still have some ongoing
25:15neurocognitive symptoms and on
25:17top of that can have some pretty
25:19significant hypocalcemic symptoms.
25:21And and can also ultimately end
25:23up being permanently hypoparent
25:25thyroid instead of hyperparathyroid
25:26where they just don't make enough
25:28parathyroid hormone anymore and
25:30they're chronically low.
25:31And it's also not good for bone health.
25:33So it's not a simple decision to
25:35make when patients have normal
25:36calcium and primary hyperpara.
25:37Me personally,
25:38I've operated on many patients who have
25:41that particular subtype of primary
25:43hyperpara and usually my criteria are,
25:46I do want to see some solid
25:48evidence of symptomatology that I
25:49feel is correctable with surgery.
25:51So kidney stones, bone disease,
25:54severe fatigue out of proportion to
25:56what you would expect in in a particular
25:59patient that is a that's an additional one.
26:03You know that alone sometimes I've
26:06been you know persuaded to operate
26:08but many times not and and also a
26:11starting calcium that is at least
26:14you know mid nines 95 or so some 9-3.
26:17But if the your if your calcium is 899.0
26:22and there is you know no strong hard
26:26signs of parathyroid disease manifestations,
26:30then I usually you know just ask
26:32the patient to bear bear with me
26:34and their endocrinologist and let's
26:35trend things over time.
26:37See if the parathyroid function worsens
26:39or if the calcium level start to rise
26:41to a safer level where we can then do
26:43potentially A subtotal resection and
26:45not leave them permanently hypocalcemic
26:46because that's a terrible condition to have.
26:49You may know some people who
26:51have that condition okay,
26:52So that's a lot of time spent
26:53on that first question,
26:54but I think it's important.
26:55There were many of you who
26:56had questions about that
26:59interoperative PTH testing.
27:01Here's another question.
27:02From what I've understood,
27:03there seems to be a greater
27:05possibility of a normal calcemic
27:06patient having multi gland disease.
27:07In your opinion, how important is
27:09interoperative PTH testing in such cases?
27:11Or could bilateral expiration
27:13be a wise alternative when
27:15interoperative PTH is not available,
27:17so interoperative PTH testing is
27:20to me it is crucial and imperative
27:23when you have that available to you.
27:26So whether you have primary
27:28hyperparathyroidism,
27:28the classic case or normal
27:30hormonal or normal Calcemic,
27:32primary Hyperpara,
27:33the Interopter PTH monitoring is very,
27:35extremely beneficial.
27:36And I, you know,
27:37recommend that it be utilized in
27:39all cases where it's available.
27:41As we talked about earlier,
27:43there's an expected decline
27:45in parathyroid hormone levels
27:46in every 5 minutes or so.
27:48And so that gives us very useful
27:51information of when we can stop the
27:53case and and be confident that we
27:55have resected all relevant disease
27:57when it comes to the parathyroid.
27:58So it's really important to do a
28:00trial for PTH monitoring that when
28:02that is not available then yes,
28:04those patients should go on to
28:06to have a four gland exploration.
28:08So identifying all four parathyroid glands
28:11and removing the glands that look enlarged.
28:14But we know that as
28:16clinicians that's not ideal.
28:17The surgeon's eye.
28:18You know,
28:19although we are confident in our eyes,
28:20and many of us wear magnification,
28:23literature and studies have shown
28:25that surgeon's eye alone is not
28:28adequate in routinely accurately
28:32determining which glands are abnormal.
28:35And that's because there could be
28:36subtle changes in the parenthetic
28:38gland that even a magnified eye
28:40don't doesn't see at quite as well.
28:42So a normal gland is about the
28:43size of a grain of rice and has
28:46a elongated Oval like shape.
28:47When parasitic glands become
28:49overactive often times they get
28:51larger and rounder and plump and
28:52sometimes that that size can get to
28:54the size of a grape or even larger.
28:56But many times particularly when you're
28:58talking about multi gland disease,
28:59these glands are about the
29:00same size and shape.
29:01There may be some very subtle changes
29:03in the size and shape of them and so
29:05that's where the hormone plays a role.
29:07So if a patient has nonlocalizing
29:10preoperative imaging that already
29:11kind of increases my thought process
29:13in or my suspicion that that patient
29:16may have multi gland disease or
29:18if they have an ultrasound that
29:19suggests that there's one enlarged
29:20gland on the right hand side behind
29:22the thyroid and a CAT scan that says
29:23they see something on the left,
29:25then that's what we call discordant
29:26imaging and there's a higher incidence
29:28of multigland disease in those cases.
29:30So I think interrupter PTH is important
29:32in all parathyroid surgery when it's
29:34available and when it's not available,
29:36yes, for gland exploration should be done.
29:40Let's see here,
29:43there is a lot of confusion about
29:44calcium intake before surgery.
29:46Some endocrinologists say to
29:47take supplements,
29:47other doctors say to hold calcium.
29:49The guidelines from the 5th
29:51International workshop say to
29:52get the recommended daily amount.
29:53Can you please comment on this?
29:55So yes,
29:56I I do agree with the the guidelines
29:59from the international workshop of
30:01getting your recommended daily amount
30:03and that's what basically can be
30:05taken care of with just an over over
30:07counter calcium supplementation.
30:08The high level calcium and vitamin
30:10D supplementation that patients need
30:12after surgery is a different amount
30:14or different dosing of calcium.
30:16Now some endocrinologists want patients
30:20to hold their calcium preoperatively
30:23so that they don't worsen the serum
30:26hypercalcemia that the patients have.
30:28And others feel that is not necessary
30:29and they're more more concerned
30:30about the bone health and the
30:32expected hypocalcemia after surgery
30:34that could become symptomatic.
30:36So they want patients to be on calcium.
30:39In my experience,
30:40I think
30:43continuing your calcium supplementation
30:45is perfectly reasonable except for
30:47those patients who already have very
30:49high serum calcium before surgery,
30:51surgery and they're very symptomatic.
30:53So patient has like a calcium of 12 or 13.
30:55They don't need any additional dietary
30:58calcium intake because that can worsen
31:00just how they're feeling in general.
31:02But those who you know,
31:03have a mild elevation,
31:04you know, 11 or less,
31:05taking their daily supplement as
31:06long as it doesn't worsen how they're
31:08feeling is reasonable because we
31:09know that we're going to be getting
31:11them to surgery and that the calcium
31:12levels will drop and they are going to
31:14need some supplementation until the
31:16normal parathyroid glands kick in and
31:18start functioning at a normal level.
31:19So Long story short,
31:20I think it's reasonable to take
31:22your daily dietary intake.
31:24If you find that your symptoms are worsening,
31:26then stop the calcium but contain the
31:27vitamin D would be my recommendation.
31:29But I would defer to what your
31:31endocrinologist are recommending for you.
31:34Okay
31:40can you have normal hormonal primary
31:43hyperparathyrosism when your calcium
31:45and PTH levels bounce around the range
31:47of PTH being 19 to 66 in my case.
31:49And so yes, your calcium
31:52and PTH levels do fluctuate.
31:54Whether you have the classical
31:56case of primary hyperparathyrosism,
31:57you know your calcium is not
31:58always going to be 11.
31:59It usually is always elevated in
32:01those cases but maybe not exactly
32:03you know 11 when you have normal
32:05hormonal primary hyperparathyroidism
32:07the calcium levels will fluctuate some
32:09as well too and but that's why it's
32:11important to exclude other sources of
32:13the hyperparathyroidism in that case.
32:15So you want to make sure that that
32:16patient doesn't truly have a vitamin
32:18D deficiency that's causing the
32:20hyperparathyroidism and not normal
32:22hormonal primary hyperparathyroidism.
32:23So normal hormonal primary
32:26hyperparathyroidism is a diagnosis
32:28of exclusion.
32:29So you have to exclude all of the
32:31reasons to have hyperparathyroidism
32:32and all your left with is this subtype
32:34of normal hormonal and that's why
32:36it's really important to investigate
32:38for kidney dysfunction and vitamin
32:39D deficiency in those patients.
32:45I would love to know why children
32:47without genetic conditions like
32:49multiple endocrine neoplasia or end
32:51up with primary hyperparathyrosome.
32:53I think that's a great question.
32:55You know, like many diseases
32:57that are common in adults,
32:59there are some that present in
33:01childhood that we just don't don't
33:03understand fully why that happens.
33:04So yes, I've operated on kids who have
33:07had primary hyperparathyrosome and most
33:09of those kids do not have a genetic
33:11syndrome that has predisposed them to that.
33:14So we really don't know why it happens,
33:17but it is found in children,
33:18not very frequently, but it does occur.
33:22What is the current status for parathyroid
33:24transplants using the patient's own tissue?
33:26Is this widely practiced
33:28and how successful is it?
33:30OK, so this is this question is
33:32kind of asking about parathyroid
33:34transplantation after a subtotal resection,
33:37or at least that's how I'm taking it as.
33:39So there are two trains of thought when
33:41you're dealing with parathyroid disease.
33:43There's those who perform a subtotal
33:46parathyroidectomy where they remove 3
33:48to 3 1/2 of the four glands leading,
33:50leaving a portion of the remaining gland
33:53intact with its natural blood supply.
33:55And there are those who perform
33:57a total thyroidectomy,
33:59an auto transplant,
34:01A portion of parathery tissue in the
34:04forearm that's that is a parathery
34:06transplant transplant of the patient's
34:08own parathery tissue and there's
34:10pluses and minuses of both camps.
34:12So in the subtotal resection,
34:15the argument is that you are leaving
34:17that a portion of that gland right in
34:19its natural element where it's always
34:21been with its intact blood supply.
34:23So you know that it will have some
34:25function and produce parathyroid hormone.
34:27And the and many proponents,
34:29many surgeons who are in favor of
34:31that like to see that they intact
34:34intec vascular supply is is maintained
34:36in those cases.
34:38And so I fall into that category.
34:40I prefer performing a subtotal resection.
34:42There are those in the camp of performing
34:45a total thyroidectomy who feel that
34:47I'm sorry total parathyroidectomy
34:49and they do so because they feel that
34:51all four of the glands are diseased.
34:53So in the event that the
34:55remaining parathyroid gland,
34:57a portion of parathyroid gland,
34:58becomes overactive and causes
35:00of recurrence of disease,
35:01it's easier to open up the forearm
35:03and resect that tissue again than it
35:05is to go back into the neck where the
35:08recurrent laryngeal nerves lie and
35:10where there's a higher risk of injury
35:12to more important structures in the neck.
35:14And I would say that in the hands of an
35:17experienced parathyroid surgery surgeon,
35:19going back into the neck,
35:21yeah,
35:21the risk is higher than if you've
35:23never had surgery.
35:24But the risk still overall is pretty
35:26low that you will have any major injury
35:28to the nerves or any or development of
35:31permanent hypocalcemia in those settings.
35:33And I would also argue that with
35:35the proper subtotal resection,
35:36the recurrence rate should be low,
35:38should be like less than 5%.
35:40So it should be pretty rare that a
35:42person who has undergone A subtotal
35:44resection ever has a recurrence again.
35:46In the event that they do so,
35:47sometimes we have younger patients
35:49in their 30s or so and then they,
35:52they had a subtotal resection
35:53performed adequately and for many,
35:55many years they had normal
35:57parathyroid function,
35:58normal calcium normal PTH levels and
36:00lo and behold, 2030 years later,
36:02they're now in their 60s or 70s and
36:04they have recurrence of disease.
36:06That remnant gland usually is large
36:08enough to be seen on imaging,
36:10but more importantly,
36:11it should be documented in their original
36:14surgical report where that gland was located.
36:16And also what I do when I leave a remnant
36:19is I leave a a titanium clip in that area.
36:22So that's how I resect that tissue.
36:24I resect the portion of parathyroid
36:26tissue that is away from where the
36:27vascular supply is coming in so that I
36:29know that I'm preserving the vascular supply.
36:31And I leave a little clip so that in
36:33the event that a recurrence occurs,
36:35either I or some other surgeon,
36:37if you know down the line I move
36:38or the patient moves somewhere
36:39else that there's a target to know
36:41the clip is in this area.
36:43So that's where that remaining
36:44one gland is left behind.
36:45But it is very rare for a patient to
36:48undergo a subtotal parathyroid resection
36:50for primary hyperparathyroidism to then
36:52have a recurrence that requires reoperation
36:58auto transplantation where you cryo
37:00preserve tissue and reimplant it.
37:02The success rates of that tissue functioning
37:05again is is variable and and low,
37:08you know about 30% or less.
37:10So there are not many centers
37:11here in the United States that
37:13cryopreserve and auto transplant
37:15tissue parathyroid tissue for those
37:17reasons there's no guarantee that
37:19that tissue will take down the line,
37:21but there are some centers that do it.
37:23We don't do that here.
37:30What is the expected recovery time and issues
37:33from a three gland hyperplasia reception?
37:37I was told I'm biochemically cured
37:39but I have residual symptoms,
37:41especially anxiety,
37:42depression, helplessness.
37:43So this brings me back to you know
37:46the reasons why I usually don't
37:49operate on normal calcemic primary
37:51hyperpara when the patient solely
37:54has neurocognitive symptoms, right?
37:56Because neurocognitive symptoms can be
37:58caused by many different reasons and
38:01not always are solely due and often are
38:03not solely due to parathyroid disease.
38:06So you have to manage expectations if if is.
38:10And so I'm always honest with my
38:12patients and I say that the cholyuria,
38:14if you have frequent urination,
38:15that's usually one of the first
38:17symptoms that clears up after
38:18successful parathyroid surgery.
38:19And that's usually in a matter of days
38:21where patients the day after surgery
38:22say that they noticed that they didn't
38:23have to get up multiple times to go pee
38:25and go use the bathroom and they're
38:28very relieved from that bone improvement.
38:31So increase in bone,
38:33bone density,
38:33we can quantify that over time.
38:35So patients have osteopenia preoperatively
38:38or osteoporosis preoperatively and then we
38:41have successful parent thyroid surgery.
38:43Those patients go on to have bone
38:45density testing usually a year
38:47later from their surgery and we see
38:49quantifiable evidence of increased
38:50bone density sometimes the often
38:52times the osteopenia is now back
38:54to normal bone density.
38:56But even in the setting of osteoporosis,
38:58there's an improvement in the bone density.
38:59So those are quantifiable measures.
39:01The neurocognitive symptoms,
39:02there are some people who definitely
39:04feel that their minds are sharper,
39:05their memory is better,
39:06the anxiety has gotten better,
39:08the depression has resolved
39:10or significantly improved.
39:11But that happens very gradually
39:14in some patients.
39:16Some it happens overnight,
39:17but in general,
39:18it's a more prolonged improvement
39:20of those symptoms over time.
39:22And often times,
39:23they're patients who don't notice any
39:26significant improvement of those symptoms.
39:28So you just have to manage expectations
39:29and be honest with patients
39:31about what you think is likely
39:32to improve and what can improve,
39:34but what can also be multifactorial.
39:37And so I think this is the case
39:39where this patient may have other
39:40reasons to have ongoing anxiety,
39:42depression and feelings of
39:44helplessness that are not solely
39:46explained by parathyroid disease.
39:50Let's see here
39:54for second parathyroid surgeries, i.e.
39:57looking for a 5th gland
39:59IS4DC to the gold standard.
40:00I would say there is no gold
40:03standard in terms of imaging
40:05studies in the reoperative setting.
40:08What we do want to say is we definitely
40:10want to have a targetable gland to go for.
40:13So whatever imaging study gets you to
40:15that targetable gland is what's ideal.
40:17And so by that,
40:18I mean there are cases where patients
40:20who have never had surgery but they
40:22have confirmed parathyroid disease
40:23and we send them for imaging and
40:26ultrasound assess to maybe a 4D
40:27CT and none of the imaging clearly
40:30shows abnormal parathyroid tissue.
40:32I still offer those patients surgery
40:34and that is because number one,
40:36I know that they have parathyroid
40:37disease based on their biochemistry.
40:39And #2,
40:39I'm experienced enough that I know
40:41where to look for the normal in the
40:44normal locations where parathyroid
40:45gland should be and in ectopic or
40:47abnormal locations like in the thymus,
40:48in the thyroid along the carotid
40:51sheet or behind the esophagus.
40:53And so I feel confident that I
40:54can find that gland even when
40:56the imaging doesn't show me in
40:58advance of where it should be.
40:59No, in the reoperative setting,
41:00that's a different story.
41:02That patient has had some parathyroid tissue
41:04removed already from a prior surgery.
41:05And whether that surgery was
41:07successful and they had a recurrence
41:08or that that surgery was unsuccessful
41:10and they had persistent disease,
41:12the anatomy now has been destroyed.
41:14There's scar tissue that has formed.
41:16I'm not sure that, you know,
41:18the particular surgeon may have said
41:19they removed the left upper gland,
41:20but they could have mistaken it and
41:22it really was a left lower gland.
41:24So in those cases,
41:25yes,
41:25I want to get some preoperative
41:27imaging that shows me,
41:29gives me a strong indication where
41:32the aberrant overactive land remains
41:33and often times it's in a normal
41:36location in the neck that just got missed.
41:38So for me the reoperative imaging
41:41studies that I send patients for
41:43is usually a 4D CT and that shows
41:46structurally where abnormal parent
41:48thyroid tissue and and instead of the
41:51ultrasound I often get a a functional test.
41:53It says to me be a nuclear medicine test
41:56because that shows functionally that
41:57can show functionally where hyperactivity
41:59of parathyroid tissue resides.
42:01And so I'd like to see that the
42:04cestamebe correlates with the 4D
42:05CT before ioffer patients remedial
42:07surgery or secondary surgery.
42:15See. So I think we've touched on all
42:18of the main questions here and I
42:22don't want to belabor the time here.
42:24So again, I want to thank you all for
42:27inviting me to give a talk on parathyroid
42:30disease and thank you for sending
42:32in such very thoughtful questions.
42:33I thank you to Rochelle and I will
42:36make sure that this is available
42:37for your group and don't hesitate to
42:40contact me anytime in the future.
42:41All right.
42:42So thanks again for the opportunity.
42:43Have a wonderful day. I'm
42:49a.