A Primer on Parathyroid Surgery in 2024

3D transparent illustration of the human neck with organs and bones visible and the parathyroid glands highlighted in blue.

This conversation has been adapted from a comprehensive interview on thyroid, parathyroid, and endocrine surgery with James Lee, MD, Chief of Endocrine Surgery.

What’s new in the treatment of parathyroid disease?

I would say that for parathyroid disease, it’s the realization that the pendulum is starting to swing back. Even if patients had high calcium levels (a normal calcium level is up until 10.2 roughly), for many, many years patients didn't get referred for parathyroid surgery until their calcium was in the 11s. And in that gray area of 10.2 to 11 oftentimes there are primary care docs or whoever was taking care of them saying, "Now, watch this. It's mildly elevated, why don't you just watch it? Why have an operation?"

But we realize as we concentrate on these parathyroid operations in the hands of experts, the complication rates are getting better, and the outcomes are getting better. More and more people with mild disease are going for operations and appropriately so. That's one of the big trends and one of the big things that as endocrine surgeons we want to really promote. 

In endocrine surgery, there is a huge amount of literature showing that the more you do of the thyroid, parathyroid, and adrenal surgery, the better your outcomes are. Patients have fewer complications, they recover faster, operative times are shorter, and cost is less. So that's one of the big pushes for endocrine surgeons is to really get that out to the public: experience matters.

What percentage of people with high calcium levels have a parathyroid issue?

That's a good question. It's probably pretty high, and it really depends on where you are. If you're in a hospital and you have high calcium levels, or if you're ill and you have high calcium levels, the odds are that you're going to have cancer of some sort. But if you're out in the wider world and generally healthy, if you have high calcium, odds are that you're going to have parathyroid disease.

It’s also important to keep in mind that the most frequent cause of abnormal labs is lab error. So you could have a high calcium level because of lab error, you might've just eaten a lot of calcium, or be really dehydrated. The important thing is that if you have a high calcium repeated with a parathyroid hormone, evaluate it going forward.

Will you explain tertiary or secondary hyperparathyroidism?

We were just talking about primary hyperparathyroidism, which is when patients have high calcium levels and high parathyroid hormone levels in secondary hyperparathyroidism. This usually happens with patients who have had a kidney transplant or need a kidney transplant. Patients with kidney failure can have very high parathyroid hormone levels because their body is constantly stimulating the parathyroid glands.

And in that scenario, all four of the parathyroid glands become very enlarged. The parathyroid hormone levels go up from a normal range of 70 to in the thousands. And a good percentage of those patients would benefit from an operation. But again, a lot of them never actually end up getting an operation because they’re waiting for a transplant and all these other things. We have a multidisciplinary clinic here, the Secondary Hyperparathyroidism Program run by Eric Kuo, that's geared towards taking care of those patients.

What role do screening and surveillance play in the treatment of the parathyroid?

From a screening standpoint, it's very clear that we underdiagnose and undertreat hyperparathyroidism.

When you look at system-wide databases, like the Kaiser system database and some others, patients will be shown to be hypercalcemic, have high calcium levels on blood tests, and they'll sort of linger around for many years before they are diagnosed and subsequently sent for treatment. So, if you have a high calcium level, don't be content to just say, "Oh, it's nothing." Make sure that people are evaluating it.

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