For Referring Physicians - Parathyroid disease Treatment

Parathyroid Disease Treatment - UCLA Endocrine Surgical Unit Brings Unrivaled Experience, Methods and Tools

The UCLA Endocrine Surgical Unit is the only surgical program in Southern California dedicated exclusively to thyroid, parathyroid and adrenal disease, offering an unrivaled level of experience and excellence along with the latest diagnostic and surgical methods and equipment.

Research confirms that experience counts when it comes to surgical treatment of parathyroid disease, with success rates of approximately 97 percent among experienced surgeons like those at UCLA, who perform in excess of 100 procedures annually, compared with rates of only 70 percent among less experienced surgeons (1, 2). Similarly, diagnostic tests to locate diseased parathyroid glands are 90 percent sensitive when performed by experienced multidisciplinary teams such as those at UCLA, compared to 30 to 70 percent in less experienced hands (3, 4).

Parathyroid Disease

Clinical update (PDF)

The parathyroid glands — four sunflower seed-sized glands located behind the thyroid gland — control the body’s calcium levels. Primary hyperparathyroidism is characterized by inappropriate parathyroid hormone (PTH) excess, that is, high PTH levels in the presence of high or high-normal calcium levels. This ongoing pathologic process causes the net loss of calcium from the skeleton into the bloodstream and urine. Complications include kidney stones, osteoporosis, musculoskeletal pain, possible cardiovascular disease, and neuropsychiatric symptoms such as fatigue, anxiety, memory loss and depression (5).

The disease affects approximately 1 percent of the adult population, and occurs three times more often in women than men. The risk of parathyroid disease increases with age, particularly after age 55. About 3 percent of postmenopausal women have the disorder, often complicating bone density loss related to menopause (6).

Diagnosis and Treatment of Parathyroid Disease

Elevated calcium levels related to parathyroid disease are typically detected during routine blood testing. Among outpatients, primary hyperparathyroidism is the leading cause of hypercalcemia, and can generally be diagnosed if calcium and intact PTH levels are simultaneously elevated. Parathyroid sestamibi scan and ultrasound are the two most useful tests in localizing parathyroid adenomas, though the sensitivities of both are highly operator-dependent (7).

Increased understanding of the multiple adverse health effects of primary hyperparathyroidism has prompted national expert groups to recommend parathyroid surgery for all patients in whom the biochemical diagnosis has been established (8). About 85 percent of patients suffer from single-gland parathyroid disease, and up to 90 percent of those are eligible for minimally invasive parathyroid surgery, which is associated with faster recovery and less scarring.

At UCLA, a minimally invasive procedure typically lasts less than 30 minutes and involves a scar measuring 1.5 centimeters – the diameter of a penny – that is hidden within natural skin folds. Intraoperative PTH measurements can determine success of the procedure within minutes of removal of the diseased gland. Virtually all patients are discharged from the hospital within 23 hours of admission.

Myths About Parathyroid Surgery

• Myth: Radio-guided parathyroid surgery improves outcomes. Multiple independent studies have demonstrated no benefit from usage of the gamma probe, leading to abandonment of the technique by nearly all expert centers (9-11). UCLA surgeons do not use gamma probes to locate parathyroid tumors during surgery.
   
• Myth: Technologists and radiologists and are most expert at administering and interpreting ultrasound tests for parathyroid disease. Surgeon-performed ultrasound has emerged as a first-line localization study (12-14). Endocrine surgeons at UCLA personally conduct and interpret diagnostic ultrasound tests for parathyroid disease using the most advanced equipment available. The study is repeated immediately prior to surgery to guide incision placement and operative strategy.
   
• Myth: Many patients are too elderly and/or frail to be candidates for parathyroid surgery. In its modern form, parathyroid surgery is very well tolerated and carries few complications. Studies show that elderly patients enjoy the same benefits from successful parathyroid surgery that younger individuals do (15).
   
• Myth: There is no standard definition of “minimally invasive” parathyroid surgery. Though many centers may claim to offer minimally invasive procedures, only a minority truly meet objective criteria for the technique, as defined by researchers at the University of California at San Francisco (16). The term “minimally invasive” is reserved for parathyroid surgery involving an incision measuring less than 2.5 cm in length. At UCLA, an incision length of 1.5 centimeters is used. To our knowledge, this is the least invasive parathyroid operation offered worldwide (17-19).

Contact Information
For more information, for consultation, or to refer a patient, call 310-206-0585 (primary line)
or 310-825-8340 (secondary line) or fax to 310-825-0189.

Participating physicians
Michael Yeh, M.D. – Endocrine Surgery, Director
Christiann Schiepers, MD – Nuclear Medicine

1. Shen W, Duren, M, Morita, E, Higgins, C, Duh, QY, Siperstein, AE, and Clark, OH. Reoperation for persistent or recurrent primary hyperparathyroidism. Arch Surg, 131: 861-867; discussion 867-869, 1996.
2. Soon PS, Yeh, MW, Sywak, MS, Roach, P, Delbridge, LW, and Sidhu, SB. Minimally invasive parathyroidectomy using the lateral focused miniincision approach: is there a learning curve for surgeons experienced in the open procedure? J Am Coll Surg, 204: 91-95, 2007.
3. Clark PB, Case, D, Watson, NE, Morton, KA, and Perrier, ND. Experienced scintigraphers contribute to success of minimally invasive parathyroidectomy by skilled endocrine surgeons. Am Surg, 69: 478-483; discussion 483-474, 2003.
4. Yeh MW, Barraclough, BM, Sidhu, SB, Sywak, MS, Barraclough, BH, and Delbridge, LW. Two hundred consecutive parathyroid ultrasound studies by a single clinician: the impact of experience. Endocr Pract, 12: 257-263, 2006.
5. Bilezikian JP, Brandi, ML, Rubin, M, and Silverberg, SJ. Primary hyperparathyroidism: new concepts in clinical, densitometric and biochemical features. J Intern Med, 257: 6-17, 2005.
6. Coker LH, Rorie, K, Cantley, L, Kirkland, K, Stump, D, Burbank, N, Tembreull, T, Williamson, J, and Perrier, N. Primary hyperparathyroidism, cognition, and health-related quality of life. Ann Surg, 242: 642-650, 2005.
7. Arici C, Cheah, WK, Ituarte, PH, Morita, E, Lynch, TC, Siperstein, AE, Duh, QY, and Clark, OH. Can localization studies be used to direct focused parathyroid operations? Surgery, 129: 720-729, 2001.
8. The American Association of Clinical Endocrinologists and the American Association of Endocrine Surgeons position statement on the diagnosis and management of primary hyperparathyroidism. Endocr Pract, 11: 49-54, 2005.
9. Duh QY. Presidential Address: Minimally invasive endocrine surgery--standard of treatment or hype? Surgery, 134: 849-857, 2003.
10. Inabnet WB, 3rd, Kim, CK, Haber, RS, and Lopchinsky, RA. Radioguidance is not necessary during parathyroidectomy. Arch Surg, 137: 967-970, 2002.
11. Kell MR, Sweeney, KJ, Moran, CJ, Flanagan, F, Kerin, MJ, and Gorey, TF. Minimally invasive parathyroidectomy with operative ultrasound localization of the adenoma. Surg Endosc, 18: 1097-1098, 2004.
12. Solorzano CC, Carneiro-Pla, DM, and Irvin, GL, 3rd. Surgeon-performed ultrasonography as the initial and only localizing study in sporadic primary hyperparathyroidism. J Am Coll Surg, 202: 18-24, 2006.
13. Van Husen R and Kim, LT. Accuracy of surgeon-performed ultrasound in parathyroid localization. World J Surg, 28: 1122-1126, 2004.
14. Kairys JC, Daskalakis, C, and Weigel, RJ. Surgeon-performed ultrasound for preoperative localization of abnormal parathyroid glands in patients with primary hyperparathyroidism. World J Surg, 30: 1658-1663; discussion 1664, 2006.
15. Kebebew E, Duh, QY, and Clark, OH. Parathyroidectomy for primary hyperparathyroidism in octogenarians and nonagenarians: a plea for early surgical referral. Arch Surg, 138: 867-871, 2003.
16. Brunaud L, Zarnegar, R, Wada, N, Ituarte, P, Clark, OH, and Duh, QY. Incision length for standard thyroidectomy and parathyroidectomy: when is it minimally invasive? Arch Surg, 138: 1140-1143, 2003.
17. Henry JF, Sebag, F, Tamagnini, P, Forman, C, and Silaghi, H. Endoscopic parathyroid surgery: results of 365 consecutive procedures. World J Surg, 28: 1219-1223, 2004.
18. Miccoli P, Berti, P, Materazzi, G, and Donatini, G. Minimally invasive video assisted parathyroidectomy (MIVAP). Eur J Surg Oncol, 29: 188-190, 2003.
19. Palazzo FF and Delbridge, LW. Minimal-access/minimally invasive parathyroidectomy for primary hyperparathyroidism. Surg Clin North Am, 84: 717-734, 2004.