Surgery

Surgical Diseases of Parathyroid and Adrenal Gland

Sonaira U. Maunting, MD
September 22, 2020

OUTLINE - Thyrotropin Releasing Hormone

DIAGNOSTIC PROCEDURES FOR THYROID DISEASES ............................. 1 Thyroid Imaging Tests

Thyroid Function Tests ................................................................................................... 1
Thyroid Imaging Tests .................................................................................................... 1 - Ultrasound
PARATHYROID GLANDS ................................................................................ 2
o Most sensitive and accurate imaging technique for detecting
Hyperparathyroidism ...................................................................................................... 2 thyroid nodules measuring dimensions, identifying structure,
Primary Hyperparathyroidism........................................................................................ 2 and evaluating diffuse changes in the thyroid gland.
Parathyroid Carcinoma ................................................................................................... 3
o Initial imaging modality of choice and should be performed in
Secondary Hyperparathyroidism ................................................................................... 3
Tertiary Hyperparathyroidism........................................................................................ 4 all clinically apparent incidentally discovered thyroid nodules.
Hypoparathyroidism ....................................................................................................... 4 o If neck adenopathy is palpated on physical examination, then
ADRENAL GLANDS ......................................................................................... 4
an ultrasound of the neck is also warranted.
Disorders of Adrenal Cortex .......................................................................................... 4 - Advantages of Ultrasound
Disorders of Adrenal Medulla......................................................................................... 5 o Most cost effective
o Noninvasive
o Widely available
DIAGNOSTIC PROCEDURES FOR THYROID DISEASES o Less expensive
- In testing for thyroid function, there is no single test that will suffice o No ionizing radiation
o Aids in interventional procedures
for assessment. The only test necessary for patients with thyroid
o Evaluate cervical nodes
nodules or a clinically euthyroid is serum thyroid stimulating
o Assess invasion
hormone or TSH o Identify small nodules
o No need for special preparation
Thyroid Function Tests
- Thyroid Stimulating Hormone (TSH)
o This reflects the ability of anterior pituitary to detect free t4
levels and it has become the most sensitive and specific test
for the diagnosis of hyperthyroidism and hypothyroidism and
in optimizing T4 therapy.
- Free T4 (tetra-iodothyronine or thyroxine) and Free T3 (tri-
iodothyronine)
o It is the second diagnostic step for confirmation in the
evaluation of nodules if TSH is abnormal.
o They are sensitive and accurate measurement of biologically
active thyroid hormones. Free T4 test is confined to cases of Figure 1. Ultrasound Findings of Malignant Thyroid Module.
early hyperthyroidism in which total T4 level may be normal
but free T4 levels are raised. o Have a particular use in evaluating the extent of large, thick,
- Total T4 and Total T3 substernal goiters (cannot be evaluated by ultrasound) and
o Total T4 reflect the output of the thyroid gland their relationship to surrounding tissues.
o Total T3 levels in the non-stimulated thyroid gland and are - Radionuclide Imaging
more indicative of peripheral thyroid hormone metabolism o Iodine 123 and Iodine 131
and ▪ Used to screen and treat patients with differentiated
▪ Therefore, not suitable as a general screening test. thyroid cancers for metastatic disease. The images
obtained not only provide information on the size and
Measurement of total T3 level is important in clinically hyperthyroid shape of the gland but also the distribution of functional
patients with normal T4 levels who may have T3 thyrotoxicosis. activity.
▪ Areas that trap less radioactivity are termed cold nodule
- Serum Thyroglobulin (Tg) with 20% risk of malignancy whereas areas that trap
o Only produced by normal or abnormal thyroid tissues. more radioactivity are called hot nodule with less than
o It is important in monitoring patients with differentiated thyroid 5% risk of malignancy.
cancer for recurrence particularly after total thyroidectomy ▪ Fat scan are not routinely used except in patients with
and RAI ablation (Radioiodine ablation) negative imaging
- Thyroid Antibodies o Technicium 99 (Tc 99m)
- Anti- Tg o F-fluorodeoxyglucose (FDG) positron emission tomography
- Anti-microsomal (PET) with Computed Tomography (CT)
- Anti- TPO

They do not determine thyroid function but rather an indicator for

underlying autoimmune thyroiditis such as Hashimoto’s Thyroiditis,
wherein 80% of patients have elevated antibody levels.

- Serum Calcitonin
o A sensitive marker for medullary thyroid carcinoma.
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 Surgery | Surgical Diseases of Parathyroid and Adrenal Gland
Primary Hyperparathyroidism
- 0.1% to 0.3% of the general population
- women > men
- It is a common disorder affecting 100,000 individuals annually in the
United States
- Characterized by increased parathyroid cell proliferation and
parathyroid hormone secretion that is independent of calcium levels
- Increased parathyroid hormone production leads to hypercalcemia
via increased GI absorption of calcium, increased production of
vitamin D3 and reduced renal calcium clearance
Figure 2. Radionucleotide Imaging of the Thyroid.

- Fine Needle Aspiration Biopsy (FNAB)

o Recommended for differential diagnosis of thyroid nodules
o It is the procedure of choice in evaluating suspicious thyroid
nodules
o Recommended for all one-centimeter nodules and above
except for hyperfunctioning nodules.
o It has limitations such as inadequate samples and in
diagnosing follicular hyperplasia
Figure 4

Causes
- Exact cause is unknown
- Radiation
- Genetics
- Diet
- Lithium therapy

Presentation
- it can present as enlargement of a single gland or parathyroid
adenoma (80%)
- multiple adenomas (15-20%) or hyperplasia
Figure 3. Histopathologic findings seen in Fine Needle Aspiration Biopsy. - parathyroid carcinoma (1%)

PARATHYROID GLANDS Signs and Symptoms

- Majority of patients have four parathyroid glands
o 2 superior glands
o 2 inferior glands
- In rare cases, some may have accessory glands
- These glands secrete parathyroid hormone that plays a role in
calcium homeostasis together with vitamin D and calcitonin
- Disorders of the parathyroid gland represent as either in the form of
hyperparathyroidism or hypoparathyroidism with symptoms of
hyper- or hypocalcemia
- (Classic Pentad):
o Kidney stones (80%)
o Painful bones (15%)
o Abdominal groans - PUD, cholelithiasis, pancreatitis
o Psychic moans - depression, anxiety, psychosis, coma
o Fatigue overtones - fatigue and muscle weakness
Patients formerly present with the classic pentad of symptoms but now
they are more likely to be minimally symptomatic of asymptomatic

Hyperparathyroidism
Diagnosis
- Hyperfunction of the parathyroid glands
- Biochemical studies
- Classified as:
o Increased serum calcium
o Primary
o intact PTH or two site PTH levels
o Secondary
o without hypercalciuria
o Tertiary
- Radiologic Tests
o BMD studies
Primary hyperparathyroidism arises from increased parathyroid o Vertebral X-ray/Vertebral fracture assessment
hormone production from abnormal parathyroid glands and results from o CT scan
a disturbance of normal feedback control exerted by serum calcium. On o Renal ultrasound/CT scan/X-ray
the other hand, elevated parathyroid levels may also occur as a
compensatory response to hypocalcemic states resulting from chronic
Presence of an elevated serum calcium and intact parathyroid hormone
renal failure or GIT absorption of calcium — this secondary
without hypocalciuria establishes the diagnosis of primary
hyperparathyroidism can be reversed by correction of underlying
hyperparathyroidism
problems like kidney transplantation for chronic renal failure. However,
chronically stimulated glands may occasionally become autonomous
resulting in persistence or recurrence of hypercalcemia after successful Treatment
renal transplantation resulting in tertiary hyperparathyroidism. - All symptomatic patients should undergo Parathyroidectomy
- Asymptomatic patients - controversy

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 Surgery | Surgical Diseases of Parathyroid and Adrenal Gland
Most authorities agree that patients who have developed complications o if the localizing studies fail to identify any abnormal parathyroid
and have classic symptoms of primary hyperparathyroidism should gland or identify multiple abnormal glands in patients with a
undergo parathyroidectomy however, treatment of patients with family history of PHPT, MEN1, or MEN2A
asymptomatic primary hyperparathyroidism has been a subject of o if a concomitant thyroid disorder requires bilateral exploration
controversy.

Indications for Surgery

- for patients who are asymptomatic and less medically prohibited:

- Single adenoma: 1 abnormal gland

- Double adenoma: 2 abnormal glands
- Triple/multiple adenoma: 3 abnormal glands

A single adenoma is presumed to be the cause of patient’s primary

hyperparathyroidism if only one parathyroid tumor is identified and the
other glands are normal which is seen in about 80% of patients with
primary hyperparathyroidism

Pre-operative Localization Tests Parathyroid Carcinoma

- Before surgery it has become routine to localize hyperfunctioning - Accounts for approximately 1% of PHPT cases
parathyroid glands, it is important to point out that imaging is not a - may be suspected pre-operatively by the presence of the ff clinical
diagnostic approach and a decision for exploration should be made manifestations
before any imaging is performed
o Sestamibi Scan Clinical Manifestations
▪ is the most widely used and complemented by - presence of severe symptom
ultrasound - serum calcium levels >14mg/dL
- significantly elevated PTH levels (5x)
- palpable parathyroid gland
- local and distant invasion

Local invasion is quite common approximately 15% of patients may have

lymphoma metastasis and 33% habits and processes of presentation.

Diagnosis
- accurate diagnosis necessitates a histologic examination
- intraoperatively:
o presence of large, gray-white to gray-brown parathyroid tumor
that is adherent to or invasive into surrounding tissue like
muscle, thyroid, RLN, trachea, or esophagus

Treatment
Operative Management - Surgical management:
- Unilateral parathyroid exploration o Neck exploration with en bloc excision of the tumor
- Bilateral standard parathyroid exploration o ipsilateral thyroid lobectomy
o modified radical neck dissection (presence of LN)
o possible RLN resection (RLN involvement)
With the introduction of pre-operative localization studies, this has
- Radiotherapy
enabled a more directed surgical approach of the parathyroid gland. The
- Chemotherapy - no role
focused approach identifies only the enlarged parathyroid gland and no
attempts are made to locate other glands. Unilateral neck exploration
Secondary Hyperparathyroidism
has several advantages over bilateral neck exploration including
reduced operative time and complications. Cause
- Chronic renal failure
Standard Bilateral Neck Exploration - Vitamin D deficiency
- Indicated if the following are met:
o if parathyroid localization studies or IOPTH are not available
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May occur in those with hypoglycemia secondary to inadequate calcium ADRENAL GLANDS
or vitamin D intake malabsorption They are paired with retroperitoneal organs located superior and medial
to the kidneys at the level of eleventh rings.
Treatment It has two parts:
- Medical management: Adrenal cortex- produces the aldosterone, glucocorticoids and adrenal
o Calcimimetics hydrogens
o Low phosphate diet Adrenal medulla – source of catecholamine hormones (epinephrine and
o Phosphate binders norepinephrine)
o Calcium
o Vitamin D intake Disorders of Adrenal Cortex
- Surgical Management: - Hyperaldosteronism
o Indications: - Cushing syndrome
▪ Bone pain, pruritus - Adrenocortical cancer
▪ Calcium phosphate product ≥ 70
▪ Calcium >11mg.dL with markedly elevated PTH Primary Hyperaldosteronism
▪ Calciphylaxis - Symptoms and signs:
▪ Progressive renal osteodystrophy o Persistent hypertension
▪ Soft tissue calcification and tumoral calcinosis o Muscle weakness, polydipsia, polyuria
o Bilateral neck exploration - Diagnosis:
o Subtotal parathyroidectomy o Hypertensive patient with coexisting spontaneous hypokalemia
o Total parathyroidectomy and Autotransplantation (K<3.2nmol/L)
o Hypokalemia while on diuretic therapy (K<3 mmol/L)
Tertiary Hyperparathyroidism o 24-hr urine for cortisol, sodium and aldosterone
- Autonomous PTH secretion persists for >1 year after a successful o CT scan/ MRI
transplant in patients - Treatment:
- Operative intervention is indicated when the following criteria are o Control of hypertension
met: o Adequate K supplementation
o Hypophosphatemia o Adrenalectomy
o Low BMD/severe osteopenia
o Symptoms and signs such as fatigue, pruritus, bone pain, Primary hyperaldosteronism results from autonomous aldosterone
peptic ulcer disease or nephrocalcinosis secretion in turn leads to suppression of renin secretion. These patients
Management: usually present with a long-standing hypertension resistant to multiple
Management is surgical with identification of all parathyroid glands. drug therapy.

- Subtotal parathyroidectomy Cushing’s Syndrome

- Total parathyroidectomy and Auto-transplantation
- Upper thymectomy

Hypoparathyroidism
Hypoparathyroidism presents us hypocalcemia which is treated
symptomatically. The most common cause is thyroid surgery yet
permanent hypoparathyroidism is rare

- Differentials for hypocalcemia:

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 Surgery | Surgical Diseases of Parathyroid and Adrenal Gland
o Bilateral adrenalectomy
- Cushing’s disease
o Transsphenoidal excision of the pituitary adenoma
o Pituitary irradiation

Adrenocortical Cancer
- Symptoms and signs:
o Functioning tumor
o Nonfunctioning tumor
- Diagnosis:
o Serum electrolyte
o Urinary catecholamines
o Overnight 1-mg dexamethasone suppression
o CT scan/MRI

Adrenal carcinomas are rare neoplasms with a worldwide incidence of 2

Cushing syndrome which refers to a complex of symptoms and signs
resulting from hypersecretion of cortisol regardless of etiology. This may
be classified as ACTH dependent or ACTH-independent
per 1 million. 50% of adrenocortical cancers are non-functioning while
the remaining secrete cortisol, hydrogens, estrogens, aldosterone and
multiple hormones
Patients present with functioning tumors often present with rapid onset
of Cushing syndrome accompanied by virilizing features while non-
functioning tumors are commonly present with an enlarging abdominal
mass or back pain, rarely weight loss, anorexia and nausea may be
present

- Treatment
o Open adrenalectomy via a generous subcostal incision or a
thoracoabdominal incision on the right side
▪ Enbloc resection tumor

- The aim of diagnostic tests in the evaluation of patients suspected of

Cushing’s syndrome are twofold. One is to confirm the presence of
Cushing syndrome and second to determine its etiology.
- Cushing syndrome is characterized by elevated glucocorticoid levels
that are not suppressible by exogenous hormone administration and
loss of diurnal variation.
- Once a diagnosis of hypercortisolism is established, further testing is Disorders of Adrenal Medulla
aimed at determining whether it is ACTH-dependent or ACTH- Phaeochromocytomas
independent Cushing’s syndrome. - Symptoms and signs:
- CT and MRI scans of abdomen can identify adrenal tumors with 95 o “classic triad”
percent sensitivity ▪ Headache
- Laparoscopic adrenalectomy is the treatment of choice for patients ▪ Palpitations
with adrenal adenomas while open adrenalectomy is reserved for ▪ Diaphoresis
large tumors more than 6 centimeter or those suspected to be o Hypertension
adrenocortical cancers - Diagnosis:
o 24 hr urine samples
- Adrenal adenoma o Plasma metanephrine levels
o Laparoscopic adrenalectomy (treatment of choice) o CT scan/MRI
o Open adrenalectomy for tumors (≥6cm) or those suspected to
be adrenocortical cancers
- Adrenal hyperplasia

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Phaeochromocytomas are rare tumors with prevalence rates ranging

from 0.3 to 0.95 percent they can occur at any age with a big incidence
in the fourth and fifth decades of life and have no gender predilection.

- Treatment
o Medical management:
▪ Blood pressure control
▪ Volume repletion
o Surgical management
▪ Adrenalectomy
• Open anterior approach

Laparoscopic adrenalectomy has rapidly become the standard

procedure of choice for existing of most benign appearing adrenal
lesions less than 6 centimeter in diameter.

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