Chapters Transcript Video Parathyroid News: Fact-checking a Century of Parathyroid Misconceptions All right, good evening folks. Thank you so much for joining us. Um We have both Lopez and I. We've been seeing this disease exclusively for For 25 years combined. We've been best of, for instance, residency in the 1990s and now we are on our own. Um working for Tampa general. They've hired us and we are continuing to see patients for parathyroid disease and continuing our dedication of this disease exclusively. We do see thyroid disease as well and do thyroid surgery, but our main focus is of course parathyroid because that's what we've done so much up. So we're going to fact check the last 100 years of parathyroid misconceptions. Thank you guys for taking time tonight to spend some time with us. We appreciate you being here and hopefully we'll keep you entertained. Okay, Parathyroid news, fact checking. A century of parathyroid misconceptions. All right. There's not really a better place to start than the beginning. So let's go way back to the 1800s. Sir Richard Owen was a famous comparative anatomy at the London Zoo and he convinced the people at the London Zoo two by an indian rhinoceros And they did so in 1834. And they housed this. He said, this is gonna be your biggest exhibit is gonna be the most popular exhibit. He was right. They did by the Rhinoceros that was housed with the elephants. But the elephant, the male elephant, about 15 years into the this rhinoceroses stay, would pin him down with his tusks and torment this poor rhinoceros For basically every day. Until finally he gored the rhinoceros in the side and the Rhinoceros died in 1849. Well, being a comparative anatomy, Richard Owen was charged with performing the autopsy well. He had done autopsies on giraffes and you know, all kinds of different animals and so apes, orang utan. So he took months dissecting this. He particularly was worried about the lungs and and the respiratory system because he noticed a cracked rib on the left side and he knew that there were respiratory problems and he saw some lung inflammation. So he took, he paid particular attention to the thyroid and the larynx. And you can see here, you can see the adam's apple and the thyroid. Maybe it doesn't make great sense to you don't have an electronic pointer. But what you see back there is what he appreciated. It was the first one to ever appreciate this. A small, compact yellow glandular body was attached to the thyroid at the point where the veins emerge and you see that little bump there. Well, he has thankfully he preserved this in a jar. Well, during that time, Owen was, he was a noted creationist and he had a public dispute with Charles. Darwin, whom we all know was the father of evolution, is um he just thought the variation of the species was from the divine creator, not because of Darwin's evolution theories. And he basically, even though he helped Darwin with some of his categorizing some fossils, he, the two never really got along very well. Darwin's theory, of course, prevailed. And the irony of it is that it was Owens work In finding Parathyroid Glands. And then the unanimous that followed him for the next 50 years, that actually did a good job of proving Darwin's theory that once they found in the necks of cats and dogs and ox and rabbits and in man, these variably positioned glands in the next that we're parathyroid glands. So now we're going to take about 30 seconds to go through 50 years of parathyroid history. Okay, so Theodore Bill Roth then starts doing Total thyroidectomy is toward the end of the 19th century and he finds that people go into text me after he figured it must be because he's taking out the thyroid and the parathyroid glands. At the same time there autopsy is being performed on patients who died with bone disease. And they were seeing in large parathyroid glands, testimony was found to be from low calcium. They figured out it wasn't from low sodium or magnesium or potassium, it was from low calcium and they could resolve it by injecting people with calcium and eventually with parathyroid extract. Well, Those were all we just covered about 50 years. They took people with trial and error to figure that out. But now that we know how parathyroid glands were discovered, let's go into the basics with Dr. Of what we now, what is very well known now. No, you're gonna have to be my point there for a second because I lost mine. Okay, no problem. Thank you appreciate it. So going back to the basics, just some basic embryology. Um Sure we all remember this from medical school and try to be precise about this. But there's four parathyroid glands in the body. We all know that to superior twin fear glands. The superior glands come from the third brink of pouch. And that will give rice the, sorry, the sapir parathyroid glands are derived from the fourth branch of pouch, the end of the term of that. And that would give rice to the parathyroid glands as well as the thyroid gland. Well the third branch will give rise to the fear parathyroid glands on the timers. So the superior glance tend to have a much better predictability in the body. Most of them are located towards the upper third behind the thyroid, while in fear, parathyroid glands are usually played towards the bottom of the thyroid and the thymus or tire atomic ligament. That's why some of these parathyroid glands can sometimes travel to the chest and upper media steinem. Next. So as mentioned before, there's two parathyroid glands to sapir wants to interfere once there for all purposes are supplied by the same artery and it is named fear territory coming from the thyroid cervical trunk. Can we have five parathyroid glands? Yes, they do happen. How often do they happen? We're gonna be touching on that a little bit later, but it's not as common as people think they do happen next. Yes, it does have a little bit of a delay Jose, but there you go. Some more basic anatomy. They're very small. Obviously there are six millimeters in length for four by two. There most of the time. Their overall location will be long and thin. They're mustard yellow collar. They went about 50 mg. Um And they're supplied by sympathetic fibers based on motor fibers. What do they produce? Well, one thing they produce P. Th and that's what gets measured in the blood is the intact P. Th that we actually look at when we're measuring somebody's P. Th they have two types of cells, the chief cells that are the ones that are responsible for the korean P. Th and the occipital cells. Despite all this knowledge, we still do not understand why the occidental's cell exists. Some basic physiology as you know, low calcium will increase your production of P. T. H. And P. Th will act on three different organs. One of them is being the bone and the bone will act on the steel class. And the osteoclasts will release calcium and phosphate into the bloodstream. It will work in the loop of henley increase, decrease in the loss of calcium in the urine and will help activate the vitamin D. To help absorb more calcium from your Gi tract. So what happens if this goes without stopping you get those osteoclasts will continue to phone, will will cause bone loss. The kidneys will be overwhelmed with filtration, you'll develop naturally. Diocese. And here's the first fact most of our patients are symptomatic data, excess calcium and repeat th both of them Is what brings calcium that 95% is talking about the amount of patients that are symptomatic from this disease. So the opposite happens if the calcium is high and the normal circus that circumstances your p th production actually goes down. So just some basic, more basic physiology at 84 Amino acids. The end terminal is the one that is the active one, as I mentioned before, bone kidneys and intestines is how the the actual hormone works right next. Yeah, okay, so after everybody um sort of is has learned about the parathyroid glands and know that they exist in humans. They are in the neck, there in variable positions they're associated with bone disease. So you start getting people that operate to take out these tumors of parathyroid glands. This uh first is done successfully in europe and that is by dr Felix Mandel and he was in Vienna Austria. It was a surgical resident and Felix Felix operated on a 34 year old tram car operator, her conductor that was admitted with a femur fracture, who had a white urinary precipitate, the diagnosed primary hyper parathyroid ism. And yes, he took a big tumor out of his neck. Um after surgery, his bone pain resolved and he was found to have his urinary precipitate cleared up. Well in the United States, we did not necessarily have such a great start as they had in Australia. This is a picture of captain Charles martel. He's a 30 year old Marine Sea captain who was worked up at Bellevue Hospital in new york city for a loss of height and vigor. You see him on the left side of that picture, a robust young man. The man on the right side of the picture of the shorter, debilitated looking man is the same man. This is after years and years of primary hyper parathyroid cysts. Um so Charles martel, He gets admitted to Bellevue Hospital. He is in fact he has a calcium of 1480s diagnosed with primary hyperthyroidism. Um, forgive me here, Michael. It says that my connection is lost on my pointer. Can you advance sure it's not. Next slide is just the next bullet point. Okay. And next And next. There you go. So the first operation on Captain Martel was in 1927. It was at Mass General. They found no parathyroid adenoma, one Normal Gland was removed next. Then the second operation was done later on the same month. And that was at Mass General. They operate on the left side. Only one normal gland was found next. For everybody counting. We're at the third operation on this man. This is his third neck operation. This one's over in New York again. No parathyroid found that's in 1929. Next. So we met fast forward a few years, May of 1932 Martel returns to mass general. He's declining in renal function and he's increasing has increasing symptoms. Pathology. Next, he is admitted To the metabolic ward at mass general for 18 months. Um, This is obviously before uh insurance insurance companies. I would imagine no one watching this presentation can have someone on their service for 18 minutes without the case manager asking what's your discharge plan? So next and again. Next next life. All right. So dr Oliver Cope was sent to perform parathyroid gland dissections on cadavers by his boss at Harvard Medical School in preparation to operate on martell for the fourth time. He did several successful parathyroid exams in the summer of 1932 and this man is ready. He's got his confidence. He's on a roll. Next. He operates on Martell three times in his neck and all of them are unsuccessful. Next martell himself then hits the library and he insists, because he's looking through here and he's finding out from surgeons in europe and other surgeons in the United States. Hey, wait a minute. These things can be in the chest. You guys have had six chances to get it out of my neck and you haven't found it. How about we go with operating on my chest? He insists on this and next. The 7th operation is undertaken and this is by Churchill and his uh by Churchill who was copes attending. And they do in fact find a large parathyroid adenoma in the media steinem. They excised only 90% of it attaching the remnant to its vascular medical right behind the sternal notch. Despite these precautions technique developed on the third post op day six weeks after the operation of renal stone became impacted in the ureter and Captain Martel died of Lorenzo spasm shortly after a surgical procedure to relieve his irritable obstruction. We could probably all agree that few patients in the annals of history of medicine have been studied as extensively as Captain Martel Next. So, parathyroid surgery in the United States obviously had its troubles in the beginning. What did the surgeons then? Really? What were their conceptions of this? They kind of didn't have it all figured out? Well, there are a number of parathyroid glands when you operate typically for go ahead. Next, they can be located anywhere you need to remove them all. There were people who advocated removing them all. So what two possible surgical results does this give you number one? The patient is not cured, has a huge scar and can't talk number to the patient is cured, but to have a huge scar and they can't talk and their intent any. Well, next signed me up for that operation. How many of us would refer our patients for that? Probably not many. Next Jose is going to talk about some of the essentials of diagnosing. Now, dr Lopez, we have a question before you get started circling back to your last section. The question came through. Um are vitamin D. Levels altered by parathyroid disease? That's a very good question actually. Um As as you saw one of the slides the calcium, it's uh it's essentially uh managed by the hormones and vitamin D. Is actually one of the hormones that is involved in keeping the calcium homeostasis. So we do see changes in vitamin D. Most of the time when we actually see probably about in the range of 70% of the time. The bottoming the level will be low. And now we're about to jump into the diagnosis. So that kind of ties into that pretty well. If you see a patient with the calcium level above 10.1 10.2 a low vitamin D. Level, that patient has a likelihood about 95% of higher of having parathyroid disease because you're high calcium is going to switch off the production of vitamin D. At the kidney level. And that's actually, we've, we've been able to prove that. So those two things high calcium, low vitamin D. Put your bed on that. It's probably going to be a parathyroid tumor. And when I say high calcium levels, um, this is not a particular slide. I didn't want to make it too busy but any calcium level. About 10.1 10.2 schumer alerted decision that somebody's suffering from primary I prepare authorities and even if the lab doesn't demonstrate that if it doesn't come as a red alert for them, hope that answers the question. Great, thank you. You're welcome next. So, the early days of cows invitation were only for those patients like Douglas mentioned earlier, those patients that have symptoms or have problems, stones, bones, abdominal groans, constipation, Thrones, Polidori, apology or the psychiatric overtones. Next. So it's not until uh Dr san gore's trying, obviously, we all learned this from medical school, we're still here today, but it's not next until the 19, Almost 1950s. Next. That The multiphasic screener begins in san Jose California. From there, it takes about 20 years Of screening before it actually becomes mainstream next. So it is in 1970 that is slightly used in places like New York California next. And what happens? What do we do with this information? Now? We have 20 years of cumulative information from the 50s to the 70s and it takes another 20 years Of elevated calcium levels for the first panel to meet and and say, Okay, now we have 40 years of history of elevated calcium levels that are quote unquote asymptomatic. And as you know, I said earlier, most of our patients are symptomatic. If you ask the right questions next. So this guideline starting 1990 and you will see with Douglas explanation, he's following me next. That not much has changed over the next 30 years. Next. Okay, go ahead, Jose. Uh, so actually I contain an imaging. So a lot of a lot of physicians say next, we're gonna get now that we diagnosed with their authority disease. We like to get a scan to confirm the diagnosis. There's no utility in confirming or excluding parathyroid disease diagnosis. But any scans out there, it should not be used as a surgical referral. You don't wait for the scan to quote unquote, be positive to consider a patient for surgery next. So, Most places that I've read says that if if the scan is done properly, either assess the maybe in an ultrasound, it will reach 92%. I actually do not think that that is true in anywhere near dog. And I would love to have 92% success of finding plants with the ultrasound or decides to maybe scan. We're lucky if we get 50 50 but now why don't we use it in the Opera Room? We use it because it's cost effective. It's cheap. We can evaluate the thyroid at the same time, thyroid pathology happens about 30% of the time in conjunction with parathyroid surgery. Uh the sensitivity lowers when you have a multi nodule goiter due to the depth of of catching up on this on the pro. We actually use it for intra thyroid parathyroid glands. We don't want to be cutting to everybody's thyroid if they don't if we don't need to to find a tumor. So we look in the usual places and then if the ultrasound shows an introductory parathyroid gland high for corn oil within the Within the lower polling authority, common things being common. That is the parathyroid and we go after. That saves a lot of time once we started doing this, it's I would say they would say start saving us a good amount of 10-15 minutes because we knew exactly where that parent. I was going to be found. If you see a parathyroid on on an ultrasound in the office, it's going to be a high put coid nodule. Um It's gonna vary in size. Most of the tumors will probably about half to one centimeters. Please do not. Biopsy does not only does it make the operation harder because it will create a scar. And it was called around the recurrent angel nerve. But it also makes the pathologist job a lot harder. Some of them will call us saying this looks like a cancer will say no it's just an old tumor that was biopsy next. So the system can has done the day of surgery. And what are we looking for? We're looking for a topic lens through a topic lens. Imagine that we're where we are operating is the diamond in the baseball field. 1st 2nd 3rd home base. What are we looking for? Anything outside of their? That's what we do the system before the day of the operation. And we're ready to take care of those tumors even if they're in the outfield next for D. C. T. Rarely used. We do use it when we have to refer a patient for a chest lesion that was not amenable to a neck excision. Um We avoided in regular standard operation because of the cost and the amount of radiation that the patient is going to be getting next. M. R. I've never used one actually. In fact never even seen one for parathyroid disease has four sensitivity and specificity. Um You could use it for a pregnant patient. We prefer just to use the ultrasound or go blindly into the patient's neck when they are pregnant. We usually do this in the second trimester. Thanks. And then the fusion scan is essentially a fusion between the system may be scanned and the four D. C. T. When do we use it failures? We do get failure's not many. Thank God. But when we have a failure we want to try to use both images and give us a pinpoint location. We don't want to operate everywhere in the neck because if we can't fix the person the first time it's unlikely to be fixed unless we have a national target or a failed operation somewhere else. We'll bring him in. We do our system maybe ultrasound if that fails, that's another indication to do a four D. C. T. In our hands next. So what's the best imaging modality? Doctor john Gottman and the N. I. H. N. Looking radiology program said it best in 1986. The only localization study and study indicated in the patient with untreated hyperthyroidism is the localization of experienced their authority surgeon. We're here for you guys next. Okay so we had from the surgery that we described earlier Um from basically around the 1930s. All the way up until 1990 we had the era of really aggressive parathyroid surgery. Actually got to the point where it was successful. The traditional operation was looking at all four parathyroid glands. A large incision was, we'll go for the details out in a bit, but it still had a lot of complications. And we had all of these calcium levels in the tens that would come out of the multiphasic screener uh into doctor's offices and they say okay we're really supposed to operate on all these people. And so we needed some sort of idea of, you know, some some authorities, some authoritative panel to get together and try to make some sense of all these uh calcium levels that were slightly elevated, that we needed to make some sense of what we're going to do with next. So in Bethesda Maryland in 1990 next there was a panel of endocrinologist, radiologists, surgeons, epidemiologist, primary care providers. And this was on the management of a symptomatic, primary high prepare authorities as well. The the asymptomatic. That's very interesting because it's a disconnect the patients that had kidney stones, osteoporosis, or a loss of renal function or hyper calcium. It crisis, they were considered to be symptomatic. It's really cinematic relief. You think of it? Um those aren't really symptoms but there are signs but those are target organ problems. And so those were all everybody agreed. Okay, all of those people need surgery. They've already gotten target organ complications from this disease. The question became, what about the people, all the other people that don't have any of those things yet? Are we supposed to send them all to surgery? And if not then what do we do with them? How do we manage them next? It's our belief that there really was a disconnect between what the panel ended up recommend recommending and what the community physicians received and how they tried to implement this busy doctors are seeing lots of patients and they need an answer to this. Am I supposed to send everybody to surgery? If not, which ones do I send him? What do I do with the ones I don't next? So what came of that? Where some guidelines everybody, I'm sure everybody here has seen these and these are basically indexes of if you're not going to operate on somebody, then they don't have those target organ effects yet. Then what things might clue you in that they're headed in that direction? So a Syrian calcium, 1 to 1.6 mg percent above normal, A 24 hour urinary calcium over 400 maybe that's leading to renal stones. Creatinine clearance is reduced by 30%. Obviously, that's leading to renal loss, bone mineral density, loss of two standard deviations at the forearm, below age matched peers. and then an age less than 50, with the idea being that we didn't really know what the expense of the burden of spending decades following a young person Without operating on them and with this disease, have, what kind of effect would it have on a young person if you follow it for 15-20 years? Also, if someone didn't agree to or wasn't going to be compliant with medical follow up in surveillance, then that would be someone that they would operate on as well. Go ahead. These suggestions, these guidelines quite honestly, were received as rigid criteria by the practice position. If you look at it, that's what they were received as they were received as qualifications for surgery. Not really guidelines. But next slide, if you look at the actual article and most people haven't read the original article, there's a whole lot of doubt and equivocation. This is not a hard and fast set of Rules that were sent out. If you really read what they said, there were only really two definitive statements in that in that initial article in 1990, those were. what was interesting about them is these were widely ignored. So what did the panel say? They said definitively? All patients with primary hyperthyroidism should be considered to be candidates for surgery. And all four meetings of that panel has said the same thing. There's no other cure for this. This is everybody should be considered at least a candidate for surgery practicing physicians. We see over another patient does not meet criteria. Another thing that panel said the results of imaging studies should seldom if ever be used as the basis for selecting patients for operative versus non operative management. We see very commonly scan is negative. Will observe next line the numerical data. However, the numerical guidelines that you saw earlier, these were actually based on a lack of much data, but they were accepted as Gospel. And if you look at when they talk in their article about serum calcium levels, urinary calcium levels, bone density scanning, this is what they ended up saying. Go backward please. Oh no, that's good. The data were not sufficient. This is a quote from the article. The data were not sufficient to justify making precise quantitative recommendations for surgery for any of the above listed tests. Nevertheless, the panel members thought that some examples should be offered as possible guidelines. That doesn't sound like a definitive statement to me. That's saying, Yeah, this seems like You seem like that calcium is getting a little high. That seems like that urinary calcium is too, is too high. It's probably going to make a kidney stone. They didn't have randomized trials saying anyone below 400 had less of a risk of a kidney stone than above 400. Next, this is another statement that most people haven't seen. This was in that article about their uncertainty. Our uncertainty about the natural history of asymptomatic primary hyperthyroidism can be likened to the understanding of hypertension and hypercholesterolemia. Before large scale epidemiologic and clinical studies were completed. No absolute clinical science or laboratory criteria can be used to identify patients who are likely to develop complications. Decisions about surgical or medical management are based on clinical judgment, on a case by case basis. The only acceptable treatment other than surgery for these patients is conscientious level. Long term medical surveillance. Go ahead right next. What was it's important to know in 1990, what was surgery like? Well, typical surgery was a large incision who was about three or 4 hours of operating time. It was general anesthesia. They were always intubated. There were numerous frozen section. There was large IV's. The patient was usually hospitalized for two or 3 days. The NIH conference and their initial guidelines were submitted and were formulated before minimally invasive parathyroid ectomy came along. This was based on the older operation next. The 1990s really did change everything worldwide. Next. We act the World Wide Web in 1991, it was invented in Switzerland. We had in a matter of almost no time really. Historically speaking Next, there's A global takeover of two way communication by the Internet. The new york times showed that about 1% of the two way communication was In the year 1993 was by way of the Internet, but by the time you get seven years later it's 51%. And then I never said another seven years later, it's over 97%. Then you get patients who have smart devices or all of us have smart devices, mobile technology, social media. So people are able to communicate with each other, exchange information. These patients who are experiencing all these other symptoms that are not really addressed by the NIH, they're tired, forgetful, aqui crabby, can't sleep there irritable and they don't have good concentration, all these things, they're finding each other and they're finding out well, there are other people with these symptoms and what are they getting done about this? Well, minimally invasive Techniques came along as well in surgery and Jose is going to talk about how those techniques came along during the 90s. Um, right around that time here in Tampa florida. Um the minimum recent radio graduated para thyroidectomy was invented um And Douglas and I were um participants of those early cases back in the late nights were both reasons here. Um The operation was then turned from a maximum invasive operation to a very small incision next short operative time next. Um The at the time only one gland was found. It was essentially focused operation and it was taken out and the surgery was done. Radio guided was the ability to compare the radio activity amongst all glands and quickly discerned disease. Parathyroid glands measuring the radio activity to do to mitochondrial activity. Was an outpatient surgery. No need for an intubation list patient was obese and the patient got to go home with a very, very low complication rate, Thanks. So some of the chunks that are used for minimum basic characteristics. And we are the gamma probe, essentially a Geiger counter measures mitochondrial activity next. And the higher accounts correspond to physiologically active plans versus normal glands that have had much less physiological activity. Now that's a tool. And even this tool has this backdrops. And if you don't know how to use this tool might as well not use anything, just use your eyes. The same thing. The same thing happens with inter operative P. Th it was invented in the eighties. Has a half life. The P. Th has a half life of about 5 to 10 minutes. The problem with interpretive P. Th it's invasive. You need an invasive I. B. And more. More than anything is the time that it requires for a to come back to result. You have a patient asleep for usually 40 to 45 minutes. Everybody says, well the machine is right here. It only takes us 20 minutes. Well that takes just to spend the specimen. The actual interpretation of the whole thing takes about 40 45 minutes. During that time we are done with our procedure because we're doing real time evaluation of every gland by using the gamma probe, our eyes and our hands as well as they are our expertise. And so how is it interpreted, interpreted? So I'll give you a little example. It dropped less than 40. It was a cure when you're using introverted p th Douglas. And I know that if R. P. Th doesn't drop below 20 there's two reasons. Usually number one, the patient has decreased renal function. And if we found all four parathyroid glands and the P. Th. It and drop it simple, we can draw that later. Or it's the first time we're thinking we must have missed something. We must we could have missed the gland. And we start thinking about re operating on that patient. Next. So dog is going to talk about Dr. in the 90s. Well, we all deal with this um the Dr. phenomenon patients immediately. Now. Remember now we've got patients who go online immediately, as soon as they diagnosed, they want to find out about their diagnosis, the advice that they've been given the doctor, they're going to go see. Well, when you intersect the 19 nineties, the World Wide Web patients being able to find each other and find out where they're being treated. And then all of the minimally invasive techniques, really not just in parathyroid disease, gall bladder surgery, appendices, surge all these different minimally invasive techniques. And you end up with this extraordinary experience that we were at the right, we were in the right place at the right time to see thousands and thousands of parathyroid patients. So we So we uh there really aren't. I mean, if you look at any combination of two surgeons, there are not two surgeons in the world who have performed more parathyroid operations than the two of us in the last decade. Over 13,000, then we've trained the next five most experienced marathon insurgency followed in this field. We're in an extraordinary position. Two really asked the original questions again. And so what would those be? How often we have all this access to all these patients? Let's find out. Those people in the 1930s only had a dozen patients in some of their studies. We can find out how often does someone actually have hyperplasia? How often do people have five marathon right clients? To somebody with a council level of 10.6 have a severity of disease? That's the same as someone with a council of 11.6 when the scan shows only one tumor does the patient typically really only have one too. The original reporters. The original scientists involved with this had very few patients to gain information from. So next After the 90s, then you got more NIH conferences. Well now you have multiple centers, lots of patients, thousands and thousands of patients that have now had parathyroid surgery. Because the techniques are so much more well tolerated. And we have a lot more information. We actually can study this disease better. Well, they met in April of 2002 again in 2008, again in 2013 the next. And if you can't say, I don't know if they can see that that well. But what this is basically showing you is each iteration of those same criteria and quite honestly what you're seeing is for the most part again you're looking at what are the actual things that people are following? We're not talking about people that already have osteoporosis, hyper calcium in crisis, the kidney stone um or reno los we're talking about people that you're monitoring. And so these guidelines of what you will monitor, they sort of just tinkered around the edges. Quite honestly, we'll go from the Z. Score to the T. Score when we're measuring texas scans and then we'll go to a fragility fracture and then we'll okay for the premenopausal women will use the score. But the post menopausal use the T. Score. And renal in renal function will follow creatinine clearance initially. And then we'll go to an estimated G. Fr. At first you need a 24 hour urine calcium and then what you don't need it. Now, you just needed the initial evaluation. And quite honestly, this is trying to the same paradigm of trying to assign people to which of these essentially qualifications for surgery. When really we're not asking the right question. The question is, are they symptomatic to start with? We now have access to thousands of patients. We know what they complain of. We know what their symptoms are. Very few are actually asymptomatic. That would be the right question to ask. Because when you say someone needs relief from their symptoms and they have the threat of all this end organ damage. Will that person should have surgery to get this fixed? Next? So a real quick we call this the balancing act. And as you can see with the balance steps towards surgery, very simple. We have to do so much surveillance to keep to take care of a patient that is not going to have an operation. That is quote unquote asymptomatic. That if you can you click through this, This one's uh, thank you. Yes. You can see all these tests at some point. Need to be ordered because we're following them and they developed a complication of watching this disease. Why not just take the patient to the opera room? Well, OK, they're hospital cost, decision, cost, time off of work, expenses, discomfort of the patient, the risk of the surgical complications. Nobody ever talks about the medications. There's multiple medications that you need to address every single one of these patients symptoms. And you can click to this really quickly. I don't want to take forever. But as you can see Every possible symptoms that the patients have next can have. Can you can use 345 medications. Next lack of interest, memory problems. Next osteoporosis, next bone pain, joint pain, muscle pain, next insomnia, next reflux, next kidney stones, Next hypertension. But how many diuretics stand diuretics? 12 beta blockers. 10 ace inhibitors. Eight days to inhibitors. 10 channel blockers, headaches. Next A 532 medications. If you cannot talk about relations, you can keep adding there and all the procedures can be associated with following somebody including a miscarriage. Well they D. N. C. And a psychological factor is not even factor into this. Some of the signs and symptoms. The disease can be pretty bad. Hair loss for females, elevated function test wondering if I have hepatitis occupations landing in the emergency room Feeling like you're not yourself, why can't we do a 25 minute operation on these patients? I ask myself that every day. Why do why do we hold this? Um guidelines like dog says like they're written stone next. So expertise comes in. Thanks. So how do we do it today? I'm going to school this really quickly to we look at your labs. If you we think you have a pair of our disease, you get a telehealth council and everything else will happen the day of surgery. We'll do the system, maybe scan and ultrasound the day of surgery. We'll give you the instructions. We go back to the opera room And the operation usually takes 25-28 minutes. Skin to skin. What happens during that time? Were able to evaluate, not explore, Evaluate four Glands in real time, 95% of the time we're able to do that. How do we know this? We know this from Pathological analysis that we've done over the last 10, 15 years. It's still an outpatient procedure. Next. Um They go home with a little decision and a band aid on their neck taking calcium. That gets win over time and we check their labs up two months and if there's a problem, we'll contact them next. Okay, So who actually who needs us? I mean, quite honestly, most patients don't need all of the expertise that dr Lopez and I have accumulated. We've been in a great position to see so many of these and do so many of these. Who really needs all of this expertise? Well, Most of the patients don't next. Most patients have a straightforward, simple problem. They have an adenoma about 70% of the time they have a single adenoma. Three normal glance in the right way. They're supposed to be. The people that probably need us are the one with unusual findings, unusual locations of parathyroid glands, glands, or tumors that are adherent to the recurrent original nerve glands that are in the chest, the tumor that's down in the chest, That is actually something we can reach from the neck. Next. Most unusual cases though they don't come in with the stamp on their foreheads though, is that I have a parathyroid man in a weird place. You don't really get any advanced warning. You don't know until you're in there and you operate. The patient actually needs the expertise right then and there. Next. So who would that be? Well, there'd be someone who's got a parathyroid tumor that's off the beaten path. If you look at I'd love to have a pointer. But I'll tell you, you look at that, the four big black dots at the top, those are salivary glands. Then down by the word anterior. In the first frame, that's there's a little black spot, that's the heart. And then you see this sort of V. Shaped thing. Well one side is that is that right thyroid load? The other side of the left thyroid living in the big black dot in the middle. That looks like to any surgeon like it's so easy. But you look at the next frame, it looks like on the right side of the patient back up. Previous. Please, yep. If you look at the R. A. O. There it's on the right side and on the L. A. It's on the left side so it looks like it's on its switches sides. And that's classically behind the esophagus. The boy does that fool a lot of people. That's the most common thing that we see that we have to re operate on someone that has been operated on in a thyroid lobes been removed and they've had a five hour operation because in the body it's really hard for a surgeon of finance. They haven't seen that. A budget act next. What's another time? Someone really needs this expertise. If it's above the beaten path, look above the thyroid lobe there, there is an extra focus of radio activity up there under the salivary gland, but above the thyroid. And you look at on the patient's right side, you can see it on every one of these films up high in the neck. That's someone who had a parathyroid gland and never made it down to the regular place. Next here, you see it and it's there's another one, an undescended parathyroid adenoma on the other side. Look at each of those and you see that extra thing up above the thyroid gland. That's the parathyroid tumor that never made it down to the regular spot. Next. Yes. This would be a case where we would that's can really did help us. You can see where the ink mark will show you. That's where we would regularly make an incision. But we would make it up higher for this so that we can go straight to that parathyroid tumor that's way up above the beaten path. So they would say in the outfield. Next. So what are some other unexpected finding obstacles? Look at this big goiter. Now, we're all looking at the thyroid gland. We can get it looking at it. The big goiter on the patient's right and a big hot thyroid nodule on the left and a little tiny little projection below that hot thyroid on the left. You can see that the extra little projection, it looks like a little foot sticking off of that hot thyroid nodule on that patients left next. Well, when we think about hormonally active tumors, other endocrine tumors. Where it's basically they find these are found in other parts of the anatomy as well. Jose will talk about one that we all have heard all about next. So this is a good picture that just kind of shows you how much work it needs to remove another tumor that produces a hormone that usually it's an incident alone. Um the incident alone was having a 2% prevalence in the population. Maybe about that for parathyroid disease. Although we're not sure next these patients that have the incident Aloma, they're gonna need chemistry or mono test. All we need is custom and p th for parathyroid disease. Next. The additional imaging that will be needed at C. T. Sometimes an MRI repeat scan for us. It's just a system maybe scan the surgery is going to be very involved as you can see. And it could be done open laparoscopic or robotic. Look how much how many organs need to be moved out of the way to remove that adrenal tumor. If it's just making a hormone, how is this different than for authorities is next? Why are we taking taking patients tumors out of the adrenal gland and going through all of this Because they are known to have an organ damage? Well why don't we think about Paris authorities is the same way we're not in a cavity. We're right below the skin and we can do a curative operation in 25 minutes. With minimum morbidity and mortality. Actually zero mortality. This carries a mortality. If you put a hole right right next to that blue thing there that's inferior vena cava. That little blue thing is the right thing. If you if you take a hole in there, the patient can examine it. And I were willing to put a patient to an operation like that even in the best hands with the risk. With pretty high risk. Yet we think about sending a patient for a parathyroid operation. Next we can compare this. This is obviously a small, small incision to take a tumor and look at the size of the incision, the size of the brain and no blood loss. Next so comparison to diabetes, I've had this discussion with multiple endocrinologists and and they all agree there like but they're both benign diseases and if you live in United States you're not going to die of high sugar of high calcium. But it causes and stage problems. Micro vascular disease, heart brain kidneys. So those pair authorities ease diabetes, increase the risk of my problems. So those pair authority disease diabetes has a decrease in black expectancy. So those pair authorities ease next Medications for diabetes will help control the sugar. But their long term commitment expensive over time. And although they slow down the progression of disease, they don't stop it. We can actually stop it for parathyroid disease. If there was a surgery for diabetes that can hear it in 2025 minutes, the line would be around the hospital and I would be doing diabetes surgery. I can tell you that right now. I'll be changing people's lives nonstop. Why don't we do the same thing for parathyroid disease? Next, next next. Okay. So fact checking the midst that we have learned next. So hyperplasia occurs in about 15 20% of the patients with high prepared part is um in fact it's about 5%. I'm gonna tell you guys why most of the time three glands are found and you're not missing that big tumor that was behind the esophagus that Douglas was showing earlier. And they say well guess what? The patient must have hyperplasia. We're gonna take three out. The patient is not fixed. Then we have to not only fix the patient but deal with the consequences of possibility. Hyperthyroidism after surgery. Hyperplasia involves all four glance after doing this for 10 years and back for 15. I can tell you this hyperplasia. Ball four Glands but not all the time. There's asymmetrical hyperplasia. We actually see that probably more often. What that means is that most of the time we'll have three glands that are bad and one land that is fair or semi spare and that's usually the gland that we leave behind. Because it's the most normal land Negative Scan. The patient must have hyperplasia. The majority of scans are negative. 50% of the scans are negative. It doesn't mean they have hyperplasia. It means they have an adenoma, 73% of patients usually have an adenoma. That when that rest the rest of time, it will be two lands And hyperplasia. As mentioned before, we feed five or 6 6% of the time. Another myth topic. Lands are common. No, they're not. The stopping glass are extremely rare. And we get to see that on the scans that we obtained the day of surgery, Parathyroid Glands can be anywhere. No, they are not. They are very predictable locations. Once you do this operation, you can find them in minutes. That's how we can get to an operation 25-28 minutes. Myth. I couldn't find it. So, it must be a topic. Sorry about it. You couldn't find it because you haven't done enough. Next. Okay, so one of the things we often used as a As an analogy is 10 Parathyroid Glands. Just be anywhere. I get that question all the time. Well, no, we always say they're like handicapped parking places. They are not just anywhere. You drive into a parking lot, you pretty much know exactly where the handicapped parking spots going to be here. You see it right next to a wheelchair ramp. Next they'll be right by the entrance to a building, another next entrance to a building. Next it will be by a crosswalk next next to an elevator. Next they do not stick a handicap parking place way out all the way to the left of the screen here, out in the middle of the parking lot, a half a mile away from the door. They look all the way to the right. You see these little yellow hash marks spaces. Those are the handicap parking places. What we're getting at is there are specific spots within the neck anatomy that these things are. And if you don't spend a bunch of time in places that these aren't almost ever located, you can move through an operation very quickly and not disturb a bunch of other tissue plants. Next. So some meds about scans, positive scans me equals a minimally invasive operation. Minimally invasive does not require positive. Skin requires expertise. More than one anonymous. Can is not a candidate for minimum basis. No, it's actually the same incision. Say more times than day surgery. If you had a tumor is showing the scan again, only about 50% of the time will be able to find the adenomas. And if there's a second one, it probably one show next, next, next, next. Just in the interest of time transfer. Go through these next next. So so Doctor Lopez. How about it? My skin only shows one tumor. You know, I thought I talked to a patient's that my my doctor just wants to operate on the left side. And clearly this patient has it too. From the website. I said to him, well, you know here we we look at both sides because we know there's a high chance you may have a second tour 23%. As I said before, you can have a second under my next patient decided to come and see us and voila, there is a proof a positive scan that localizes to the left. This patient would have had an operation and not be cure. Instead he had the same operation. Can debate that maybe even faster. And he went home with two tumors and face the same day next. How about nets about supernumerary glance? Everybody's heard about that. One of the things that people hear about it, you can have all, you can have 567 parathyroid glands. Well, the myth is five parathyroid glands occurring whatever number of patients fact we can never know. Next. You have to assume a patient has four Parathyroid Glands, two on each side until they prove you wrong. Once you have documented for parathyroid glands confirming the remaining glands are normal. If that patient has persistent disease, then you can start thinking about 1/5 parathyroid gland. Okay. But otherwise you would never know when to stop operating. If people could have 567 parathyroid, what if they could have three on one side and one on the other? You have no idea when you can stop and you would basically open every tissue plane in the neck, defeating the purpose of a minimally invasive operation by converting it to a maximum invasive operation for something that occurs in less than 1% of patients. Next myths about calcium bones, higher calcium equals more symptoms. No symptoms do not depend on the degree of calcium elevation. Higher calcium equals more autonomous. No multiple adenomas do not correlate with calcium levels. They can occur at any calcium level higher calcium. So I must have to have a bigger incision. The incision size does not depend on the calcium, Mild hyper calcium. It's just barely elevated. Just it's like 10.4. That means I have mild disease. Your disease severity is not dependent upon the degree of calcium elevation. Next, as we say, it's the time not decline. We studied, as you see there, that was the largest study ever published 20,000 patients and that was from our former practice at normal Parathyroid Center. And what it showed us is that the serum calcium of 10.6 as impressive as many patients are ever going to see. We studied the incidence of symptoms and those signs those target or organs of people with calcium levels below 11 and above 11 and there was no difference. So now we have all these thousands of patients we know it's symptoms they experience and we know that it's not really any different based on the calcium level. Keep going dr Pooley. We, sorry, interrupt. We have actually quite a few questions that came through um regarding the calcium level based on the degree of calcium elevation and p th elevation. Whether it's PHP T vs. 20 or 20 H. P. T vs. three Oh versus parathyroid cancer seems Parathyroid cancer is usually very severe hyperglycemia and P. T. H. Levels Greater than 400. And your experience, can we look for, what can we look for? I would tell you if you're in looking for parathyroid cancer, you're going to think it's a lab error. A parathyroid cancer is really, it's so rare in all this experience. I've seen two cases, same in two cases of parathyroid and all these thousands of cases twice. And it's not someone that has a calcium level of 11.6 and a p. th of 280. It's someone who has a calcium 15.6 and a p. th of 1880. And you say this cannot be right. There's no way that that is right. We have to send them back to the lamp and it comes back something really obnoxiously high again secondary and tertiary. We we purposely, for the sake of time we ended up having to kind of not be able to talk about secondary and tertiary secondary being with dialysis and tertiary and transplant patients. But the transplant patients have levels that look like primary hyper breath out isn't secondary. Okay, I'll let you go ahead with the french and we're gonna be, there's a couple of lives moving forward and I'm gonna be able to touch them that really quickly, but you'll be able to help people, you know how to quickly differentiate between those. Go to the next slide. So click through the rest of this and then we had two other questions in the queue. We can wait till the end though. Yeah, sure. Okay, go ahead and click through this. All right, go ahead and uh um if you can increase, take me and dug out, probably. Um Thank you. Here's a good living what living in the 10s is And living in tents means that adults should not live in the tents. Most of our calcium levels are in a tight spot. And most of all live in the midnight as we age, our calcium levels will drop. I've had 80 year old patients that after 30 the calcium levels go to 8.99.1 and that's normal for them. The point being that are calcium will bear with age. But any adult after the age of 30 or so that has persistent calcium elevations above 10.1 10.2, you got to raise the flag for parathyroid disease. And this is a good example. This this calcium levels start somewhere in the 10.6 area with a P. Th if I can read it well, I think it's about 50 or 60. And then on the next lab, the calcium drops to 10.2 and a p. th of 64. So some people will think, well this patient actually doesn't have for authorities is as you continue to add data to this, you see that the calcium levels don't even go above 11 as high as it goes 10.9. And on the right hand side you'll see an inappropriately elevated P th and sometimes above normal, showing that this patient in fact has primary high prepare authority is um All along this is as exciting as it's going to get A lot if you're expecting your patient to jump into the 11th to pull the trigger and say you need an operation, you're wasting your time. One of the things that dog was going to talk about was how many people never even reach 11. And it's a huge amount of patients that never even reach 11. So, don't wait for that to happen next, next this next slide. Actually, if you can read it shows the opposite, in other words, shows like the patient has primary high prepare authorities um at the beginning with elevated calcium levels and parathyroid hormone levels. Then their calcium levels kind of normalized and end up end up going to the normal level as time goes by. Yeah, the p th goes up. So this patient can be told that they have primary I prepared authorities um based on the beginning or the first set of labs that we see there. Then they can be told that they have normal, consuming high prepared authorities. Um and they can also be told that they have secondary high prepare authorities um to keep things clear if your calcium is elevated persistently as it has been here and your parathyroid accelerated, That is primary secondary patients are actually patients that have been losing calcium and parathyroid glands become overactive over time for that to happen. You gotta be near reno dialysis with G. F. R. Is less than 30 and your calcium levels have to be chronically low. Anything that makes you lose calcium either from your G. I. Tract or your renal system, It's one of its what's going to cost secondary. And the tertiary patient is that patient that now has a renal transplant that ends up getting a functioning transplant and is able to keep calcium back in the system. But the parathyroid glands are overactive and they cannot shut themselves down. So that's what we call tertiary next next. So remember normal calcium levels In the 9th patients, above 10, usually not normal. And one of the myths that we want uh to the bunk right now is that patients say that if the calcium levels and the p th levels have a lot of variability that's making the picture actually. Um not as clear, it's actually clarifies the picture for us, those changes in calcium and parathyroid hormone levels. That variability. It's one of the things that we use to make the decision if somebody has full authority disease or not next. So symptoms, we can scroll through this really quickly. But the one at the very beginning, I said that most of the patients are symptomatic, And I still believe that I did not believe it when I started practicing this. I said, I cannot believe that that many of our patients are symptomatic. And over time it's been proven that over 95% of our patients are symptomatic. So, has there ever been a disease with so many non symptoms That's so commonly is referred to as asymptomatic? I've never seen one next. So, if you really look at this and I guess our parting thoughts here is that this is a curable disease. Um We have a readily available screening tool and it's the standard chemistry panel that we all get as patients and we all obtain as doctors as part of an annual visit. We have a known benign pathological lesion that's responsible for the disease. The lesion is located outside of a body cavity. There's a minimally invasive, well tolerated outpatient procedure and a clean part of the anatomy with minimal risk of blood loss. The cure rates approach 98, in expert hands. They don't all have to come to us. There are experts all over the place, I mean, and select centers around the country, but it's something we want people to think of as a Something you cure. The mortality rate of this operation is essentially it's not people don't really die of this procedure anymore. Complication rate is well under 1%. So if I could say anything we have a lot of diseases that can't be cured this one we can cure. So that's what I'd say. Let's put this one in the wind calm and the patients probably. Thank you. Yeah. Next. Um Thank you guys for spending your night with us and giving us an hour of your busy time. We appreciate everybody that's been hanging in there. A couple of take home points. Um Here are phone numbers and um maybe may take us out of the picture and blow that up. And if people want to maybe I guess maybe if you wanted to take a picture with a point, I'm sure a couple of take home messages, calcium levels above 10 are never normal. You can check him every week every couple of weeks. Um we don't need a scan. We'll be happy to see patients without any imaging. Um, if you suspect parathyroid disease, feel free to pick up the phone, give us a call, sends an email. We'll be happy to help sort some of these things out. We're here to help. Thank you again. Thank you so much. And before we log off, there were two questions in the queue that I think are important to answer the first one, the incidents of two gland disease versus three gland diseases, usually low based on published data in your experience, Is this true? Part two of the question, sorry. From those patients with one gland versus two or three gland disease, what is the incidents of recurrence and in what duration of time? Okay, that's what I say. I'll go with incidents and then you can go with recurrence of disease. But incidents of that um Single adenomas are typically about 70%,, 70, a little over 70% of people with primary hypergrowth. Itis The incidence of a second disease, Gland is about 20-25%. And then there are people that have three adenoma is no, it's not hacker pleasures. They actually, there are people that have three adenomas and that's just a couple of percent of people. Um Those if you're doing four gland explorations in your goal of your procedure is to see all four parathyroid glands and leave only normal parathyroid glands behind. Well then you've identified what was going to cause the recurrence. So those recurrence rates in our mind are the same as if someone had a solitary adenoma. If you were doing a minimally invasive operation as some places do and they get good results, They'll just take out one. But the patient had to adenomas. Well then that chance has to be about 20-25% Jose with that of recurrence. I'm saying if you all you do is take out one and that the incidence of two disease glands is 20 to 25% of it. Was that that's correct. And the other thing is that, you know, obviously based on age, we know that some patients are more likely to have more than one gland. So Um if I'm operating a 20 on a 20 year old and I found an adenoma on a normal plan, I know that my opera, she's pretty much done at that point because the chances of them having hyperplasia is nearly zero. But if I'm operating somebody about the age of 65 and I find one abnormal plan and a second abnormal plan. I'm not even thinking hyperplasia. I'm thinking I got a final four. Why? Because it's either three adenomas, it's hyper pleasure. But whatever reason at that point, multi gland disease happens more often. So much so that once you hit about, you know, in your eighties, the chances of having double enormous, it's about 50% or more. So that's important having four glands evaluated at the time of the operation. Now, long term, nobody really knows what is the incidence of long term. And here's why this operation is done differently in many places. If you really think about it, sometimes somebody will do one side, somebody will do a focus operation. Somebody will do a foreground exploration in our hands, recurrences long term. Well, hopefully they're very low because we're doing a foreground exploration to start with. Excellent. Thank you. And the last question for tonight, if the patient has Hashimoto's disease, is there an increased risk of hype of parathyroid word is um, hyper para hi, sorry, hypo para hypo para, if they have hashimoto's disease. No, I don't think so. Um, one thing that does happen with Hashimoto's disease is that they're, parathyroid glands tend to be smaller. So again, we've learned that from experience that you're operating somebody with hashimoto's disease. Take your time. And here's why those parathyroid glands are tend to be smaller and you want to identify them. Parathyroid tumors. And Hashimoto's patients tend to be very small in general and difficult to find. Hashimoto's patients tend to have a lot of lymph nodes as well. So all those things are sand traps that you can fall into. If you're too aggressive of a surgeon, you can simply very easily injure those small parathyroid glands of the hash motivation have, and that that inflammation, you know that inflammation of the thyroid tends to sort of draw the parathyroid, the little tiny parathyroid to you, or have kind of almost been sort of sucked inside the capsule of the thyroid gland makes them harder to find. So I wouldn't say the incident is higher. I would say it's more likely to happen if you don't know what you're dealing with and you're not careful what you're doing your operation. Published June 9, 2021 Created by
