Hyperparathyroidism
This is a condition where the parathyroid glands are secreting too much parathyroid hormone (PTH).
There are 3 causes of hyperparathyroidism: primary, secondary/renal and tertiary. Primary hyperparathyroidism is the most common form and is characterized by an autonomously functioning gland or glands. Secondary hyperparathyroidism happens most commonly in patients with vitamin D deficiency and kidney failure. Lastly, tertiary hyperparathyroidism can be thought of as a renal hyperparathyroidism patient who then received a kidney transplant. We treat these patients much like a primary hyperparathyroid patient although the lasting effects of kidney failure on the parathyroid glands requires a high level of expertise to judge normalcy.
Symptoms of hyperparathyroidism can be broad and vague, often only being attributed to high calcium once the condition has been reversed. Some of the most common complaints are memory loss, fatigue, mental fog, depression, nausea, abdominal pain, constipation, diarrhea, bone pain, joint pain and muscle aches.
What are parathyroid glands? They are very tiny, fragile glands that sit adjacent to the thyroid gland regulating our blood calcium levels. Many times these are the size of a few grains of rice and can easily hide in the normal neck fat. While we generally have 4 glands, our body only needs one to function without notice. Normally, when blood calcium levels fall, the parathyroid glands release a hormone called PTH. PTH causes the bones to release calcium stores, the kidneys to resorb more calcium and the gut to absorb more from our diet by activation of vitamin D. When blood calcium levels are back to an acceptable range the PTH level should fall within minutes. This is a constant, all day process that happens without thought.
In primary hyperparathyroidism, one or more of the glands has become adenomatous and autonomously functioning by secreting PTH needlessly. The gland continues to produce PTH hormone despite calcium levels above what's required. To make a diagnosis, we simply need two laboratory values: a PTH and calcium level. When the calcium is high and the PTH is non-suppressed, you have hyperparathyroidism. There is also an emerging condition called normocalcemic hyperparathyroidism. This diagnosis is made carefully and only after all other possible conditions have been ruled out by your endocrinologist.
The cure for primary hyperparathyroidism is surgery. When PTH levels are inappropriately high they leach our bones of fortifying calcium and push those high loads of calcium through the kidneys. The bones get weak and the kidney become damaged as a result. Surgically removing the offending gland(s) can stop the process in an instant.
In renal hyperparathyroidism, kidney failure causes a decrease in vitamin D activation and increased phosphate levels. Combined together, these cause the calcium levels to drop and the PTH levels to increase. Over time, some people begin to have rising calcium levels that require medications to prevent damage throughout the body. If a new kidney can be transplanted, it may correct these issues. For those that are either waiting on the transplant list or ineligible at this time, surgery can be performed.
Surgery for renal hyperparathyroidism is called a subtotal parathyroidectomy. This is the removal of 3-3.5 glands. Patients require intensive intravenous post-operative management of their calcium levels over the course of many days. Care of this condition requires special expertise and experience such as that gained by Dr. Temmermand. We will coordinate with your nephrologist as to how best to manage your condition.
Other common causes of secondary hyperparathyroidism such as vitamin D deficiency and use of certain medications (thiazide diuretics, lithium, etc) will be evaluated by your endocrinologist before proceeding with surgery.
Tertiary hyperparathyroidism is not super common. It happens when a patient with renal hyperparathyroidism is finally able to have a kidney transplant yet still has persistent disease. The cure for this condition is also surgical, blending the surgical approaches of primary and renal hyperparathyroidism. Treatment is usually aggressive so as to protect the transplant.
Lastly, some patients have undergone parathyroid surgery only to find out that their blood calcium is still high or that it returned to normal for a period of time but has become elevated again. Either of these scenarios could require additional surgery. A strong collaboration between Dr. Temmermand and your doctor will be necessary to make the best recommendations for you.
Learn more about minimally invasive parathyroidectomy and how it can cure you.
Types of Thyroid Cancer
By far, this is the most common form of thyroid cancer.
This is fortunate because it carries an excellent prognosis with long term survival near 100% for most patients. Treatment is often centered around surgery although in select cases it can be reasonable to watch it closely. If surgery is the best choice for you, we will plan to remove half of the thyroid, the whole thyroid and occasionally the lymph nodes of the neck if involved.
Diagnosis of papillary thyroid cancer is most often made in one of two ways, either fine needle aspiration (FNA) or found by accident. When the diagnosis is made by FNA we then have the luxury of tailoring your surgery accordingly. This gives us the best chances at a single surgery to provide a cure. The next most common scenario is that when we perform surgery on a goiter the pathologist finds a small accidental cancer next to the main mass. In those cases, no further treatment is needed because the cancer will have already been removed. A less common "accidental" diagnosis is when it is found in the lymph nodes of the neck before being identified in the thyroid itself.
In recent years we have scaled down our surgical aggression toward this biologically non-aggressive subtype of thyroid cancer allowing for less surgery which has led to less complications and improved quality of life. What was once a massive incision, excessive in-hospital stays with drains and high risk to the critical structures near the thyroid, has now transitioned to minimally invasive, outpatient surgery while often allowing the noncancerous half of the thyroid to remain in the body.
Sometimes after surgery we will recommend radioactive iodine to help eliminate microscopic thyroid tissue in higher risk cases. Generally, we reserve this conversation until after the final pathology report has been completed (usually 1-2 weeks after surgery).
Below is a link to the America Thyroid Association. There is an excellent PDF that can be printed for your reference.
Nearly 10% of all thyroid cancer will be follicular. Like papillary thyroid cancer, this type also has a favorable prognosis.
While treatment is often centered around surgery, observation is a potential option in select cases. The most common surgery is a hemithyroidectomy (removal of the diseased half of the thyroid gland).
Diagnosis of follicular thyroid cancer isn't usually made until after surgery. We often remove half of the thyroid gland because a thyroid nodule has a fine needle aspiration (FNA) biopsy suggesting a follicular lesion. On needle biopsy both benign and cancerous lesions of follicular nature appear similar. The final determination must be made by a pathologist using a whole specimen. Fortunately, once the thyroid tumor has been removed it is often the case that no further treatment will be needed.
Alike to the trends in the treatment of papillary thyroid cancer, we have begun to temper our surgical aggression toward this biologically non-aggressive thyroid cancer allowing for less surgery which has led to less complications and improved quality of life. What was once a massive incision, excessive in-hospital stays with drains and high risk to the critical structures near the thyroid, has now transitioned to minimally invasive, outpatient surgery while often allowing the noncancerous half of the thyroid to remain in the body.
Sometimes after surgery we will recommend radioactive iodine to help eliminate microscopic thyroid tissue in higher risk cases. Generally, we reserve this conversation until after the final pathology report has been filed (usually 1-2 weeks after surgery).
Below is a link to the America Thyroid Association. There is an excellent PDF that can be printed for your reference.
This is a less common form of thyroid cancer. It accounts for roughly 1-2% of cases.
It requires special knowledge of thyroid pathology and surgery in the head & neck. Unlike the most common forms of thyroid cancer (papillary and follicular) this has different biologic behavior. It mandates more thorough surgery and prophylactic management of the neck lymph nodes. You will also need additional blood tests and imaging prior to surgery.
Medullary thyroid cancer can occur spontaneously or be part of a specific gene mutation called RET and associated syndromes. If you have not been screened for this, we will help complete the evaluation before surgery.
Below is a link to the America Thyroid Association. There is an excellent PDF that can be printed for your reference.
This is a very serious diagnosis and should be addressed as such.
If you have been told that you have this diagnosis, please request an urgent appointment with Dr. David Temmermand by phone or email.
Below are links to the American Thyroid Association website with additional information on anaplastic thyroid cancer. We encourage you to become well educated about this condition.
At the Thyroid and Parathyroid Surgery Center of New Jersey, Dr. David Temmermand is one of the most highly skilled head and neck endocrine surgeons in America.
