A doctor does not want to confirm a diagnosis of primary hyperparathyroid disease or refer for surgery until the adenoma is visible on a scan – Avoid The Pitfalls That Delay Diagnosis & Treatment

Avoiding Pitfalls That Delay Diagnosis & Treatment of Primary Hyperparathyroid Disease is a series of blogs that we will posting in order to shed light on the most common issues patients face that delay diagnosis and surgical treatment.

#3 A doctor does not want to confirm the diagnosis or refer for surgery until the adenoma is visible on a scan. 

We often hear patients say that their physicians do not want to confirm the diagnosis until the adenoma is seen on a scan. However primary hyperparathyroidism is diagnosed biochemically through blood work.

A scan should not be necessary to confirm the diagnosis.

Learn more here:  The American Association of Endocrine Surgeons Guidelines for Definitive Management of Primary Hyperparathyroidism – October 2016

In other instances, patients report that the physician will confirm the diagnosis, but will not refer for surgery until a positive scan confirms the location of an adenoma.

Why is such an emphasis placed on a positive scan?

Surgeons who perform focused exploratory surgeries directed by preoperative localizing studies will want and need a scan to know exactly where they will find the adenoma(s), as the surgery is being directed by the localizing study.  GP’s and/or Endocrinologists understand this, so they may be reluctant to refer a patient for surgery until they are able to provide the surgeon with the information they believe is needed to move forward with surgery.

If a surgeon plans to perform a bilateral exploratory surgery, a scan may not be required. During a bilateral exploratory surgery, the surgeon plans to search for and assess all four glands. Every patient should be made aware that the amount of time spent exploring in the neck impacts how much scar tissue results. It requires an expert to locate these small glands, that are each the size of a grain of rice, without excessive exploring. 

Why is this important? Expert surgeons (those who perform a minimum of 50 parathyroidectomies a year) should have a high surgical success rate. Do not be shy about asking a surgeon the number of parathyroid surgeries they perform and their success rates. Unfortunately,  not all first surgeries are a success.  Should a second surgery becomes necessary, excessive scar tissue may prevent having a subsequent successful surgery. As a result of the scar tissue, a positive scan is almost always required for a re-operation if attempted. 

There are surgeons who are able to perform a 4-gland check without using the typical or traditional bilateral exploratory techniques. In our cases, a four-gland check was performed in approximately 20 minutes without the need to explore. A sestamibi scan was performed on the day of surgery only for the purpose of confirming that the adenoma(s) were not located in more unusual places, such as the chest or jaw. This generally confirms that the adenoma(s) and healthy glands, that will also be checked during the surgery, are located right behind the thyroid gland where they should be.

Parathyroid surgery is surgeon specific.  As always, it is important to advocate for yourself… ask questions to fully understand the surgical plan and the level of expertise of the surgeon.

Learn more about the various types of localizing studies on the American Association of Endocrine Surgeons Patient Education Site: http://endocrinediseases.org/parathyroid/diagnosis_localization.shtml

If you missed the previous blogs in the series Avoiding Pitfalls That Delay Diagnosis & Treatment of Primary Hyperparathyroid Disease here are the links to catch up…

#1. Your doctor reports your serum blood calcium is in “normal” range . What could be the problem? 

#2. Slightly elevated calcium values are ignored. 

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