My Account of Hyperparathyroidism and Parathyroid Surgery Part 2
If you recently found out that your doctor suspects that you have hyperparathyroidism, please read Part 1 of my story. This Part 2 discusses the medical tests that are required when hyperparathyroidism is suspected.
On July 15, 2008, I met my Endocrinologist, Naaznin J. Lokhandwala, M.D. at Beth Israel Deaconess Medical Center. After much research online, I recognized that my hyperparathyroidism was unfolding as if right out of a WebMD article.
I remember sitting in the waiting room and watching the doctors come in and out- anxiously wondering who my new doctor would be. Surprisingly, Dr. L. is a young, petite Indian woman, and just about the only Dr. who didn’t make an appearance in the waiting room. An even younger medical student was assisting Dr. L. He asked me about my symptoms and family history. Doctor L. physically examined my thyroid for any abnormalities. I was relieved when she found nothing unusual.
While I was almost certain that surgery would be recommended, I held onto the hope that there might be another option. Because of my elevated calcium levels and parathyroid hormone levels, Dr. L. recommended that I have additional tests. To evaluate my kidney function I needed an abdominal x-ray for kidney stones. To determine the amount of extra calcium in my urine, I needed a 24 hour, urine calcium output. To determine if I was experiencing bone loss, I needed a bone density test. Most importantly, the doctor needed to get a view of my pararthyroids to see if one was enlarged and for that, I needed a Sestamibi scan.
As if taken directly from one of the pages that I read online, Dr. L. told me that my hyperparathyroidism was most likely being caused by one enlarged parathyroid gland and that surgery to remove the enlarged gland is the only treatment for primary hyperparathyroidism.
Once all test results were in, Dr. L. expected she would be transferring my case to the parathyroid surgeon on staff at BIDMC, Peter Mowschenson, M.D. – who is the surgeon that I wanted to perform my surgery. I was anxious about having the surgery, yet, relieved that this piece fell right into place.
Fortunately, I was able to have my blood work and my x-ray that same day as my initial appointment with Dr. L. An abdominal x-ray would determine if I had developed kidney stones as a result of the excess calcium in my urine. Kidney stones (ureterolithiasis) result from stones or renal calculi (from Latin ren, renes, "kidney" and calculi, "pebbles") in the ureter. The stones are solid concretions (crystal aggregations) formed in the kidneys from dissolved urinary minerals.
The tiny nuggets (pictured) that look like granola are kidney stones, which range from as small as a grain of sand to as large as a golf ball. If I had a kidney stone that was too large to pass, it could have required an additional surgery like tunnel surgery. In tunnel surgery, the doctor makes a small cut into the patient’s back and makes a narrow tunnel through the skin to the stone inside the kidney. With a special instrument that goes through the tunnel, the doctor can find the stone and remove it. Another surgery to remove a kidney stone requires a Ureteroscope. A ureteroscope looks like a long wire. The doctor inserts it into the patient’s urethra, passes it up through the bladder, and directs it to the ureter where the stone is located. Ouch. Fortunately, my x-ray was negative for kidney stones.
24-hour urine calcium output measurement
I’ll always remember this test in which I had to collect every drop of urine for an entire day. This test measures the amount of calcium excreted in urine collected over 24 hours. What made it interesting was the day of the test; I had to take my kids to their swimming lessons. Among the beach chairs, sand toys and towels, I had a large backpack that was transporting my jug of urine and the little seat that I had to use. I marched across the sand, in front of all the other moms, with my backpack full of urine. Thank goodness the restroom was clean and there was plenty of room to “conduct my test”.
The test results did reveal an elevated level of calcium output in my urine at well over 300 mg/24 hours. The normal levels for an adult are: <300 mg/24 hours (<7.5 mmol/24 hours) with low dietary calcium intake of 200 mg/24 hours.
Bone Density Scan
Bone density scanning, also called dual-energy x-ray absorptiometry (DXA) or bone densitometry, is an enhanced form of x-ray technology that is used to measure bone loss. DXA is today's established standard for measuring bone mineral density (BMD).
Bone density testing is strongly recommended for women who are post-menopausal, over 5 feet 7 inches and/or thin (less than 125 pounds) and not taking estrogen. It is also recommended for women who have a personal or maternal history of hip fracture or smoking.
A bone density scan would reveal if I had suffered any bone loss due to the presumed parathyroid tumor that was making too much PTH hormone, causing my bones to release calcium constantly into the blood stream. This could cause my bones to lose their density and hardness (it is the calcium that makes them hard). Loss of calcium from bones is called osteoporosis. Bones which are osteoporotic are more likely to break.
The bone density scan consisted of a series of what appeared to me to be typical x-rays, which took about thirty minutes. The scans of my spine, neck, hips and forearms revealed that despite my condition, I still had a normal bone density.
Parathyroid (Sestamibi) Scan
A Technetium 99m Sestamibi scan is a nuclear medicine test that uses safe nuclear molecules to make pictures of the parathyroid glands to help locate a single parathyroid adenoma in primary hyperparathyroidism.
For this scan, I was injected with c99m-sestamibi which is a very mild and safe radioactive agent which is absorbed by the overactive parathyroid gland. (Sestamibi scans are also used in nuclear cardiac muscle imaging and in the detection of very early stage breast cancer.)
I had to wait two hours and twenty minutes for the nuclear medicine to be fully absorbed by the parathyroid. The principle of the procedure is that the Tc99m-sestamibi is absorbed at a greater rate in a hyperfunctioning parathyroid gland than in a normal parathyroid gland.
The scan took a painfully long time. Three different views of my neck were taken and each view took fifteen minutes. The worst part was having my head inside a dome and the rest of my body sandwiched between this machine. I remember looking up at the dome and from the corner of my eye, seeing the x- ray machine pinning the rest of my body down. I suddenly felt claustrophobic and panicked. I felt my body getting ready to try to escape. Instead, I quickly thought to close my eyes and did so for the remainder of the test. This got me through it.
Sestamibi imaging is correlated with the number and activity of the mitochondria within the parathyroid cells. The enlarged parathyroid adenomas have a very high insatiability for sestamibi verses the clear cell parathyroid that have almost no imaging quality at all with sestamibi.
Approximately 60 percent of parathyroid adenomas may be imaged by sestamibi scanning. My results were in and the document read, “Faint focus of increased tracer uptake overlying the lower pole of the left lobe of the thyroid gland, consistent with parathyroid adenoma.” Translation – my lower left parathyroid gland was indeed the culprit and I was off to meet the surgeon.
In Conclusion -
This concludes part 2 of a this three-part series. In part 1, I discuss my experience with hyperparathyroidism- the symptoms, causes and treatment. In part 3, I will retell the details of the actual surgery and recovery.
For myself, I know that I find comfort when I can discuss a health issue such as primary hyperparathyroidism with someone who has had the experience. It is my hope that having read this, you are feeling better about this very treatable, straightforward disorder.