Parathyroids and Hyperparathyroidism

Parathyroid and Hyperparathyroidism

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Normal parathyroid glands as seen during a thyroidectomy. The large arrow points to the superior parathyroid. The thinner arrow points to the inferior parathyroid. The forceps points toward the recurrent laryngeal nerve. The patient’s head is toward the right.

http://emedicine.medscape.com/article/127351-overview

Parathyroid glands are small glands of the endocrine system that are located behind the thyroid. There are four parathyroid glands which are normally about the size and shape of a grain of rice. They are shown in this picture as the mustard yellow glands behind the pink thyroid gland. This is their normal color.

parathyroids_diagram

The sole purpose of the parathyroid glands is to regulate the calcium level in our bodies within a very narrow range so that the nervous and muscular systems can function properly. Although they are neighbors and both part of the endocrine system, the thyroid and parathyroid glands are otherwise unrelated. The single major disease of parathyroid glands is overactivity of one or more of the parathyroids; that’s hyperparathyroidism.

http://www.endocrineweb.com/conditions/parathyroid/your-parathyroid-glands

EXECUTIVE SUMMARY:

Hyperparathyroidism is when your parathyroid glands produce too much parathyroid hormone, which is supposed to regulate calcium levels in your body.  It can lead you to feel fatigued, and hyperparathyroidism can also affect your bone health, potentially leading to osteoporosis.

Hyperparathyroidism is usually caused by a non-cancerous tumor.  It can develop on one or more of your parathyroid glands (you have 4).  The tumor will over-produce parathyroid hormone.

To treat hyperparathyroidism, the tumor is removed.

Overactivity of the Parathyroid Gland

The primary disease of parathyroid glands is overactivity—too much parathyroid hormone is produced. This is called hyperparathyroidism. Under this condition of hyperparathyroidism, one or more of the parathyroid glands behaves inappropriately by making excess hormone regardless of the level of calcium. In other words, the parathyroid glands continue to make large amounts of parathyroid hormone, even when the calcium level is normal and they should not be making hormone at all. Over-production of parathyroid hormone by overactive parathyroid glands (hyperparathyroidism) can rob you of your health, making you feel run down and tired, causing osteoporosis, and many other serious problems. Fortunately, hyperparathyroidism can be fixed with newminimally invasive surgery techniques in most people in under 20 minutes.

What Causes Excess Hormone Production?
The most common cause of excess hormone production is the development of a benign (non-cancerous) tumor in one of the parathyroid glands. This enlargement of one parathyroid gland is called a parathyroid adenoma, and it accounts for 96% of all patients with primary hyperparathyroidism.

The most common situation is that one of the parathyroid glands has developed a tumor that is secreting all the hormone. The other 3 glands are small and are responding appropriately to the high calcium by becoming dormant.

This out of control parathyroid gland is rarely ever cancerous (less than one in 2,500); however, it slowly causes damage to the body because it induces an abnormally high level of calcium in the blood, which can slowly destroy a number of tissues. Parathyroid adenomas typically are much bigger than the normal pea-sized parathyroid and will frequently be about the size of a walnut.

Approximately 3% or 4% of all patients with primary hyperparathyroidism will have an enlargement of all 4 parathyroid glands, a term called parathyroid hyperplasia. In this instance, all of the parathyroid glands become enlarged and produce too much parathyroid hormone. This is a much less common scenario, but the end results on the tissues of the body are identical.

An even rarer situation occurs in less than 1% of the people who have 2 parathyroid adenomas while having 2 normal glands. This is very uncommon and can make the diagnosis and treatment of this disease a bit tricky.

How Many Parathyroids Are Affected?
A scientific study of 6,331 patients with primary hyperparathyroidism examined how many glands typically go bad in this disease. This study included data collected on a portion of patients with this disease over 10 years (1987-1997). The complete data and statistical analysis was published in March 1998 by Dr. James Norman’s group in the Journal of the American College of Surgeons.

The results are as follows:

  • 95.5% = one enlarged, overactive gland (termed a single adenoma)
  • 4% = 4 enlarged, overactive glands (termed four-gland hyperplasia)
  • 0.5% = 2 or 3 large glands (termed multiple adenomas)
  • <1% = cancer of the parathyroid

Some experts believe the incidence of multi-gland disease (hyperplasia and multiple adenomas) is slightly over reported. This data is obtained from patients who have undergone a full neck exploration and had all of the glands biopsied. Therefore, the data is based on a microscopic examination and not on whether any hormone is produced. It is unknown if these other glands would be clinically active (produce hormone).

The only way to know is to remove only one gland while leaving the others untouched and then following these patients for a number of years. The bottom line is that somewhere between 94% and 96% of all patients with hyperparathyroidism have one bad gland and 3 normal glands.

Symptoms of Hyperparathyroidism
Since hyperparathyroidism was first described in 1925, the symptoms have become known as “moans, groans, stones, and bones.” Although most people with primary hyperparathyroidism claim to feel well when the diagnosis is made, the majority will actually say they feel better after the problem has been cured.

This can only be known retrospectively when patients are allowed to comment on how they feel several months after the operation.

Many patients who thought they were asymptomatic pre-operatively will claim to sleep better at night, be less irritable, and find that they remember things much easier than they could when their calcium levels were high.

In some studies, as many as 92% of patients claimed to feel better after removal of a diseased parathyroid gland, even when only 75% claim they felt “bad” before the operation. Patients with persistently elevated calcium levels due to overproduction of parathyroid hormone also can have complaints of bone pain.

In the severe form, bones can give up so much of their calcium that the bones become brittle and break (osteoporosis and osteopenia). This problem is even more of a concern in older patients. Bones can also have small hemorrhages within their center that will cause bone pain.

Other symptoms of hyperparathyroidism are the development of gastric ulcers and pancreatitis. High levels of calcium in the blood can be dangerous to a number of cells, including the lining of the stomach and the pancreas, causing both of these organs to become inflamed and painful (ulcers and acute pancreatitis).

Another common presentation for persistently elevated calcium levels is the development of kidney stones. Since the major function of the kidney is to filter and clean the blood, they will be constantly exposed to high levels of calcium in patients with hyperparathyroidism. The constant filtering of large amounts of calcium will cause the collection of calcium within the renal tubules, which leads to kidney stones.

In extreme cases, the entire kidney can become calcified and even take on the characteristics of bone because of deposition of so much calcium within the tissues. Not only is this painful because of the presence of kidney stones, but in severe cases, it can cause kidney failure.

Potential Dangers of Hyperparathyroidism

  • Severe osteoporosis and osteopenia
  • Bone fractures
  • Kidney stones
  • Peptic ulcers
  • Pancreatitis
  • Nervous system complaints

The incidence of these problems depends primarily on the duration of the disease and its severity. Everybody will lose bone density, which is progressive. Pancreatitis and ulcers are much more rare. Even though the majority of patients claim they feel “just fine” when this disease is diagnosed, almost 80% of them claim to feel better (sleep better, etc) 3 months after the problem has been fixed. Do not elect to undergo surgery (or decide not to do so) based upon how you feel. Remember, the typical patient has had this disease for several years before it was ever found because its symptoms are so silent. The good news is that it can be cured with a routine operation that carries a success rate of about 95% and a complication rate of around 1% or less. Some centers are even performing minimally invasive surgery for this disease, which can be accomplished under local anesthesia.

Diagnosis:

Hyperparathyroidism is relatively easy to detect because the parathyroid glands will be making an inappropriately large amount of parathyroid hormone in the face of an elevated serum calcium. This is straightforward and simple to measure.

Treatment Options for Primary Hyperparathyroidism
The only 2 choices available for patients with primary hyperparathyroidism are to simply do nothing or to have the diseased parathyroid gland (or infrequently, more than one diseased parathyroid gland) surgically removed.

It’s important to understand that parathyroid disease will get worse. It won’t go away on its own. Remember, it is caused by a tumor that has developed from one of the parathyroid glands. Waiting will just allow the parathyroid tumor to grow bigger.

ROJoson’s Experiences (old files):

parathyroid30002

Renal stones

parathyroid0003

Nephrocalcinosis

 

parathyroid30001

Bone deformity in a child with hyperparathyroidism – genu valgum (knock-knees)

parathyroid20001

Increased levels of parathyroid hormone (PTH) lead to increased osteoclastic activity. The resultant bone resorption produces cortical thinning (subperiosteal resorption) and osteopaenia.

parathyroid20005

parathyroid40003

Brown tumour (also known as osteitis fibrosa cystica or rarely osteoclastoma) is one of the manifestations of hyperparathyroidism. It represents a reparative cellular process, rather than a neoplastic process.

parathyroid20002

Multiple punched-out lytic lesions

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Multiple punched-out lytic lesions

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Osteosclerotic lesions

parathyroid30004

Osteosclerotic lesions

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Salt and pepper sign of the calvaria refers to multiple tiny hyperlucent areas in the skull vault caused by resorption of trabecular bone in hyperparathyroidism.

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Parathyroid adenoma

 

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Severe kyphosis

parathyroid_yesteryears (2)

Lytic lesion on the bone

parathyroid_yesteryears (3)

parathyroid_yesteryears (4)

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Patient X

Nephrocalcinosis

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Left ureteral stone

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Table shows the course of a patient with hyperparathyroidism.

Date Calcium PTH CREA SESTAMIBI ULTRASOUND/XRAY
1/17/2011
3/31/2011 Nephrocalcinosis
4/2011 97.9 (53-115)
9/11/2011 1.97 (2.02-2.60)
12/20/2011 Sponge kidney + kidney stones
8/22/2012 121(15-65)
9/8/2012 2.66(2.15-2.57)
2/26/2013 110.41 (50-1000 kidney stones in Urether
3/6/2013 1.51( 1.13-1.31) 81.8 (49-90)
3/19/2013 125.88(50-100)
4/16/2013 79.6(45-84)
4/23/2013 1.60 (1.13-1.31)
4/24/2013
5/9/2013 145 (50-100) Urether stones
7/2/2013 149.21 (50-100)
7/9/2013 2.87(2.2-2.6)
7/11/2013 2.77(2.15-2.57) Urether stones
7/15/2013
7/22/2013 145(45-84)
7/23/2013 Nephrocalcinosis;nephrolithiases;ureterolithiases
8/1/2013 6.68 (4.48-5.28) Ionized 173.59 (10-65) IRMA NEGATIVE IMAGE
8/3/2013 IMAGE NEGATIVE Thyroid and Neck Ultrasound;thyromegaly
8/20/2013 153 (45-84)
8/23/2013 Increase calcific densities inferior pole left kidney,decrease in number of calcifications in the area of left distal urether
9/17/2013 185.99(50-100)
9/28/2013 137 (45-84)
10/17/2013
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