Patient Care & Services

The Division of Endocrine Surgery provides patients with definitive diagnosis and treatment of the following endocrine diseases of the thyroid, parathyroid, adrenal glands, and pancreas.

Information by Endocrine Organ

THE ADRENAL GLAND

Anatomy of the adrenal glands
Function of the adrenal glands
What is the adrenal cortex?
What is the adrenal medulla?
What are adrenal tumors?
What is a pheochromocytoma?
What are the symptoms of pheochromocytoma?
How is pheochromocytoma diagnosed?
Treatment for pheochromocytoma
What is an aldosteronoma?
What are the symptoms of an aldosteronoma?
How is an aldosteronoma diagnosed?
Treatment for aldosteronomas
What is Cushing’s syndrome?
How is Cushing’s syndrome diagnosed and treated?

Anatomy of the adrenal glands:
Adrenal glands, which are also called suprarenal glands, are small, triangular paired organs located in the back of the abdomen above each kidney. The adrenal gland is really two glands in one.  Each gland has an outer layer called the cortex and an inner layer called the medulla. The outer cortex gives the gland a characteristic yellow orange color. The cortex is divided into three zones. The outer zone makes and secretes a hormone called aldosterone. The central zone makes up most of the cortex and makes and secretes adrenocortical steroids or cortisol. The inner zone makes and secretes small amounts of sex hormones including testosterone, estradiol and dihydroepiandrosterone. The inner layer or the medulla synthesizes and secretes norepinephrine or noradrenaline and epinephrine or adrenaline.

Function of the adrenal glands:
The adrenal glands work interactively with the hypothalamus and pituitary gland in the following process:

1. The hypothalamus, a part of the central nervous system, releases hormones, which stimulate the pituitary gland.  One of these is Corticotropin releasing hormone (CRF).
2. The pituitary gland, in response to CRF will produce adrenocortical trophic hormone (ACTH).  ACTH stimulates the adrenal glands to produce corticosteroid hormones (cortisol).

Both parts of the adrenal glands - the adrenal cortex and the adrenal medulla - perform very separate functions.

What is the adrenal cortex?
The adrenal cortex, the outer portion of the adrenal gland, is essential to life by secreting hormones that have an effect on the body's metabolism, on chemicals in the blood, and on certain body characteristics. Some of the hormones produced by the adrenal cortex include:

1. Glucocorticoids are essential for human life. The principle glucocorticoid in man is cortisol, which controls the body’s use of fats, proteins, and carbohydrates.   Cortisol is produced by the middle part of the adrenal cortex. Cortisol secretion is at its highest in the early morning and at its lowest at night. Serum cortisol levels are regulated by a feedback loop mechanism involving the pituitary gland. The release of ACTH or adrenocorticotrophic hormone from the pituitary is the main stimulus for cortisol secretion. Normally the gonads (the ovaries in women and the testes in men) are the principle source of sex hormones in men and women. However the adrenal gland can produce some of these from the inner part of the adrenal cortex.

2. Mineralocorticoids.  Aldosterone is the major mineralocorticoid in man. It plays a key role in regulating the amount of fluid and the balance of electrolytes in our body. It stimulates the re-absorption of sodium and the loss of potassium in the kidney. By causing the kidney and other tissues to retain sodium, aldosterone increases the amount of fluid in our body. Aldosterone is regulated by a system called the renin angiotensin system. When there is a decrease in blood flow to the kidney, renin is secreted into the blood stream. This then activates angiotensin in the liver and another form of angiotensin in the lung. This stimulates aldosterone synthesis and secretion from the adrenal glands (aldosterone physiology illustration).

What is the adrenal medulla?
The adrenal medulla, the inner part of the adrenal gland, is not essential for life, but helps a person in coping with physical and emotional stress. The adrenal medulla secretes catecholamines. These hormones have wide ranging effects on almost all tissues and organs in the body. Catecholamines increase oxygen consumption and heat production by the cells in the body. They stimulate the breakdown of sugars in the liver and inhibit the secretion of insulin. This causes elevation in blood sugar.

1. Epinephrine (Also called adrenaline).  This hormone increases the heart rate and force of heart contractions, facilitates blood flow to the muscles and brain, causes relaxation of smooth muscles, helps with conversion of glycogen to glucose in the liver, and other activities.  These are known as beta effects.

2. Norepinephrine (Also called noradrenaline).  This hormone has little effect on smooth muscle, metabolic processes, and cardiac output, but has strong vasoconstrictive effects, thus increasing blood pressure. The latter is known as an alpha effect.

What are adrenal tumors?
Tumors of the adrenals are rare. However, when present, they can cause a multitude of disorders by secreting an excess of certain adrenal-produced hormones. Clinical syndromes can result.  When these tumors secrete hormones the syndromes that occur with tumors of the adrenal cortex are Cushing’s syndrome and Conn’s syndrome. Pheochromocytoma results from hormone secreting tumors of the medulla.  Some adrenal tumors may not secrete excessive hormones (nonfunctional adrenal incidentalomas) but may need to be removed because of increasing size and to exclude the possibility of cancer.

What is a pheochromocytoma?
Pheochromocytomas are catecholamine producing neuroendocrine tumors arising from the adrenal medulla or extra adrenal sympathetic nerve tissue. Tumors in these latter areas are called paragangliomas. Pheochromocytomas have a prevalence of 1-2 per 100,000 adults. They account for 0.1-0.01% of cases of hypertension. Most pheochromocytomas occur sporadically and we do not know what has caused them. However 10-20% or more may be part of what is known as the multiple endocrine neoplasia type II syndromes or other inheritable conditions in which the pheochromocytoma results from genetic defects that have been inherited.  There are urine and blood tests that are used to diagnose this condition. Once the diagnosis is made a CT scan or MRI can identify if the tumor is in the adrenal gland or outside of the adrenal gland. Tumors outside of the adrenal gland can occur anywhere from the neck down to the pelvis.

What are the symptoms of pheochromocytoma?
Pheochromocytoma causes hypertension which can be present all the time or come on in episodes or paroxysms. It can also cause headaches, palpitations and sweating. Many patients will have atypical symptoms including anxiety, tremulousness, abdominal pain, vomiting, weight loss, visual disturbances, shortness of breath and cardiac failure. The initial finding may be a consequence of hypertension such as heart attack or stroke.

Pheochromocytoma can be deadly because of these problems. Therefore it is important to diagnose them and treat them expeditiously. An increasing number of pheochromocytomas are being diagnosed “incidentally” (up to 30%) by CT scans or MRI performed for other conditions.  Each individual may experience symptoms differently.

The symptoms of pheochromocytoma may resemble other conditions or medical problems. Always consult your physician for a diagnosis.

How is pheochromocytoma diagnosed?
In addition to a complete medical history and physical examination, diagnostic procedures for pheochromocytoma may include:

1. Blood and urine tests- A 24 hour collection of urine is used to measure catecholamines, metanephrine and vanillylmandelic acid levels. The latter are the breakdown products of catecholamines. It is also possible to measure plasma metanephrines and normetanephrines. This is a very sensitive blood test for diagnosing this problem. Genetic testing and counseling may be offered in some patients with inheritable conditions.

2. Computed tomography (CT or CAT scan) or magnetic resonance imaging (MRI) - are non-invasive procedures that takes cross-sectional images of the adrenal or other internal organs; to detect any abnormalities that may not show up on an ordinary x-ray

3. Radioisotope scan (MIBG scan) - uses radioactive substances introduced into the body to create an image of the functioning adrenal gland.  The patient needs to be off certain blood pressure medications and foods prior to the test

Treatment for pheochromocytoma:
Once diagnosis and localization of the tumor has been made patients should be prepared for surgery since this is the best treatment. Preparation consists of giving medicines to block the effects of the catecholamines. The first type of blocking medicine is an alpha blocker. There are different medicines that accomplish this but they will blunt the vasoconstriction that has occurred from the catecholamines. If there are problems with a rapid heart rate or palpitations then beta blockers are also given. It is important to have an experienced team treating pheochromocytomas since the preoperative and operative management can be quite complex. Laparoscopic adrenalectomy is a safe and effective way of treating most pheochromocytomas. A skilled surgeon is needed for this but the anesthesia team must also be experienced in dealing with the blood pressure changes and heart rhythm changes that occur during the operation. With this team approach that is present at the University of Miami excellent results are obtained and patients will have marked improvement in all of their symptoms. They also will be relieved of the threat of having a life threatening heart attack or stroke. Many pheochromocytomas can be removed laparoscopically using 3 to 4 half inch incisions (a laparoscopically removed pheochromocytoma).  Some pheochromocytomas including those outside the adrenal gland (called paragangliomas) may require the traditional open surgical procedure. Most pheochromocytomas are benign but 10% may be malignant. It may not be possible to tell even when the tumor is removed if it is malignant. So patients with pheochromocytoma have to be followed for the rest of their life to be sure they don’t have a recurrence.

What is an aldosteronoma?
An aldosteronoma is a benign tumor of the adrenal that over-secretes aldosterone. This adrenal cortex hormone plays an important role in regulating the body’s salt, potassium, and fluid balance. 

What are the symptoms of an aldosteronoma?
The association of high blood pressure, low potassium, and an aldosterone producing adenoma was first described by Dr. Jerome W. Conn.  Patients with symptoms of aldosterone over-production caused by a tumor in the adrenal cortex (an adenoma) have Conn’s syndrome. This syndrome is characterized by high blood pressure, low potassium, tiredness, muscle weakness, and passing of large volumes of urine particularly at night (nocturia).   Aldosteronomas are usually small (<1 inch) yellow tumors that occur most frequently in middle-aged adults.

How is an aldosteronoma diagnosed?
The usual screening test is to measure the serum potassium level. If it is low, diagnostic tests are done including measuring blood and urinary aldosterone levels and blood renin levels. In Conn’s syndrome, the aldosterone is elevated and the renin is suppressed. If these tests are diagnostic then imaging studies are done to see if a tumor can be localized. Since these tumors are small they can be hard to find even with the best CT or MRI scan. Some patients may have no obvious radiographic tumor but one adrenal is affected (unilateral primary adrenal hyperplasia) and they can benefit from surgical removal. Other patients may have both adrenals affected with no visible tumor (idiopathic hyperaldosteronism) and surgery will not help.  In these situations blood has to be drawn from each adrenal vein (so called adrenal venous sampling) in order to measure aldosterone levels to be sure which adrenal has the tumor. The symptoms of hyperaldosteronism may resemble other conditions or medical problems. Always consult your physician for a diagnosis.

To summarize: In addition to a complete medical history and physical examination, the diagnostic procedures for aldosteronoma may include:

1. Blood and urine tests to measure potassium and hormone levels

2. Computed tomography (CT or CAT scan) or magnetic resonance imaging (MRI) – are non-invasive procedures that take cross-sectional images of the adrenal or other internal organs; to detect any abnormalities that may not show up on an ordinary x-ray

3. Adrenal venous sampling- an invasive test performed by a radiologist where a catheter is placed in the adrenal veins to measure the hormone level and confirms the tumor location. 

Treatment for aldosteronomas:
When the condition has been diagnosed and the tumor has been localized it is treated by removal of the adrenal gland. This is best done with a laparoscopic adrenalectomy.  Almost all patients will no longer have problems with low potassium after they have had their tumor removed. More than half of the patients will have improvement of their blood pressure so they do not have to take any medicine at all. Another quarter to a third will be improved but still have to take some medicine for their blood pressure.

What is Cushing’s syndrome?
Cushing’s syndrome is a rare disorder that has a prevalence of 10 patients per 100 million population per year. It can be classified into pituitary dependent or ACTH dependent Cushing’s syndrome which is also known as Cushing’s disease. Most patients with Cushing’s syndrome will have this problem. However 10 or 15% of patients will have a tumor in the adrenal gland and another 10 or 15% will have a tumor outside of the adrenal gland that is making adrenocorticotrophic hormone or ACTH. These latter patients have what is known as ectopic ACTH syndrome. Cushing’s syndrome is due to excess cortisol secretion. It causes characteristic symptoms including obesity of the trunk and thinning of the extremities, a thickening at the base of neck called a buffalo hump, a rounding of the face, weakness of the proximal muscles, thinning of the skin, hirsutism or an increase in hair, easy bruisability, depression, osteoporosis, high blood pressure and glucose intolerance or diabetes. Cortisol has widespread effects on metabolism and organ function and prolonged exposure can be detrimental to the body. The symptoms of hypercortisolism may resemble other conditions or medical problems. Always consult your physician for a diagnosis.

How is Cushing’s syndrome diagnosed and treated?
The various causes of Cushing’s syndrome can be sorted out by doing blood tests and radiologic images of the adrenal gland. This is important because tumors in the adrenal gland causing Cushing’s syndrome are best treated by removal. Ectopic ACTH tumors are also best treated by removal. Cushing’s disease or pituitary dependent Cushing’s syndrome is usually treated by removing a small microscopic tumor from the pituitary gland. Removing both adrenal glands will completely reverse this problem of Cushing’s disease and is done when a rapid reversal of the patient’s symptoms is needed. The best way to remove the adrenal glands and their tumors are laparoscopic adrenalectomy. This can be done safely if there is no risk of cancer. 

In addition to a complete medical history and physical examination, diagnostic procedures for a cortisol producing tumor may include:

1. Blood and urine tests to measure hormone levels

2. Computed tomography (CT or CAT scan) or magnetic resonance imaging (MRI) -are non-invasive procedures that take cross-sectional images of the adrenal or other internal organs; to detect any abnormalities that may not show up on an ordinary x-ray.

THE PANCREAS

Anatomy of the pancreas
Functions of the pancreas
What is pancreatic cancer?
What are the symptoms of pancreatic cancer?
How are pancreatic tumors/cancers diagnosed?
Treatment for pancreatic cancer
What is the Whipple procedure?
Can I have a minimally invasive pancreas operation?

Anatomy of the pancreas:
The pancreas is an elongated, tapered organ located across the back of the abdomen, behind the stomach. The right side of the organ (called the head) is the widest part of the organ and lies in the curve of the duodenum, the first division of the small intestine. The tapered left side extends slightly upward (called the body of the pancreas) and ends near the spleen (called the tail).

The pancreas is made up of two types of tissue:

1. Exocrine tissue.  The exocrine tissue secretes digestive enzymes. These enzymes are secreted into a network of ducts that join the main pancreatic duct, which runs the length of the pancreas.

2. Endocrine tissue.  The endocrine tissue, which consists of the islets of Langerhans, secretes hormones into the bloodstream.

Functions of the pancreas:
The pancreas has digestive and hormonal functions:

1. The enzymes secreted by the exocrine tissue in the pancreas help break down carbohydrates, fats, proteins, and acid in the duodenum. These enzymes travel down the pancreatic duct into the bile duct in an inactive form. When they enter the duodenum, they are activated. The exocrine tissue also secretes bicarbonate to neutralize stomach acid in the duodenum (the first section of the small intestine).

2. The hormones secreted by the endocrine tissue in the pancreas are insulin and glucagon (which regulate the level of glucose in the blood) and somatostatin (which prevents the release of the other two hormones).

What is pancreatic cancer?
Pancreatic cancer is the fourth most common cancer in men and women in the US, according to the American Cancer Society. The majority of pancreatic cancer cases occur in people 50 years of age or older.

There are several types of exocrine pancreatic cancers, some of the more common ones are:

1. adenocarcinoma of the pancreas - the most common type of pancreatic cancer; occurs in the lining of the pancreatic duct.

2. intraductal papillary mucinous tumors (IPMN’s) – a cystic type of pancreatic tumors that can progress to cancer.

3. cystadenocarcinoma - a rare cystic pancreatic cancer

There are several types of endocrine/islet cell tumors of the pancreas, including:

1. gastrinoma - a tumor which secretes above normal levels of gastrin, a hormone which stimulates the stomach to secrete acid and enzymes. Gastrinomas can cause peptic ulcers and diarrhea.

2. insulinoma - a rare pancreatic tumor that secretes insulin, the hormone that lowers glucose levels in the blood. This tumor is rarely malignant.

3. vipoma – a tumor that secretes vasoactive intestinal peptide, a hormone that causes a large volume of diarrhea.

4. glucagonoma - a tumor that secretes glucagon, a hormone which raises levels of glucose in the blood, leading to diabetes and a characteristic skin rash.

5. nonfunctional – a tumor that arises from the endocrine cells of the pancreas and may or may not secrete a hormone like pancreatic polypeptide (PPoma).  These tumors do not cause hormonally related clinical symptoms.  These tumors are usually malignant.

What are the symptoms of pancreatic cancer?
The following are the other most common symptoms of pancreatic cancer. However, each individual may experience symptoms differently. Symptoms may include:

1. pain in the upper abdomen
2. poor appetite
3. weight loss
4. jaundice (yellow eyes, dark urine and light colored stools)
5. indigestion
6. nausea
7. vomiting
8. diarrhea
9. fatigue

The symptoms of pancreatic cancer may resemble other conditions or medical problems.  always consult your physician for a diagnosis.

How are pancreatic tumors/cancers diagnosed?
In addition to a complete medical history and physical examination, diagnostic procedures for pancreatic tumors may include:

1. ultrasound - a diagnostic technique which uses high-frequency sound waves to create an image of the internal organs.  This tool can also be used in the operating room by the surgeon to look for small tumors of the pancreas
2. computed tomography (CT or CAT scan) - a non-invasive procedure that takes thin cross-sectional images of the pancreas or other internal organs; to detect any abnormalities that may not show up on an ordinary x-ray.
3. magnetic resonance imaging (MRI) - a non-invasive procedure that produces two-dimensional views of an internal organ or structure.
4. octreotide scan – uses radioactive substances introduced into the body to create images of the internal organs and identify endocrine tumors.  The test takes 3 days.
5. endoscopic retrograde cholangiopancreatography (ERCP) - this procedure involves inserting an endoscope (viewing tube) through the mouth, stomach, and into the small intestine. A special dye injected during this procedure shows the ducts in the biliary and pancreatic system.
6. endoscopic ultrasound (EUS) – this procedure involves inserting an endoscope (viewing tube) through the mouth into the stomach, and the small intestine.  A special probe with an ultrasound is used for imaging of the tumor.  A biopsy of the tumor can also be obtained
7. biopsy of the pancreas – this can be done using a needle introduced under the guidance of CT scan or EUS
8. special blood tests – CA 19-9, chromogranin, gastrin, pancreatic polypeptide, insulin, vosoactive intestinal peptide (VIP), and somatostatin.

Treatment for pancreatic cancer:
Specific treatment for pancreatic cancer will be determined by your physician based on:

1. your age, overall health, and medical history
2. extent of the cancer or tumor
3. type of cancer
4. your tolerance of specific medicines, procedures, or therapies
5. expectations for the course of the disease
6. your opinion or preference

Treatment may include:

1. surgery (to remove the tumor, part or the entire pancreas)
2. radiation therapy - high-dose x-rays used to kill cancer cells.
3. chemotherapy - drugs used to kill cancer cells.
4. pain medication
5. oral enzyme preparations
6. insulin treatment

What is the Whipple procedure?
A surgical procedure used to remove the head of the pancreas.  A Whipple procedure is usually performed for tumors of the head of the pancreas but it can also be done for pancreatitis or other benign conditions.    Because the pancreatic head is surrounded by many important body structures like the duodenum, stomach, bile duct, and large arteries and veins, this procedure is very complex.  Your surgeon can usually determine if your tumor can be removed surgically or not by obtaining a CT scan of the pancreas and or an Endoscopic Ultrasound.  A Whipple procedure can last anywhere from 4 to 8 hours.  Most patients stay in the hospital 7-10 days and recover over a period of 2 months.  Our surgeons have extensive experience with this procedure.

Can I have a minimally invasive pancreas operation?
Some tumors of the pancreas can be removed using minimally invasive techniques including laparoscopy or hand assisted laparoscopy.  Each case will be evaluated individually to see if you are a candidate for these procedures.

THE PARATHYROID GLANDS

Anatomy of the parathyroid glands
Function of the parathyroid glands
What is a parathyroid tumor?
What is hyperparathyroidism?
What are symptoms of a parathyroid tumor?
How is hyperparathyroidism diagnosed?
Treatment for a parathyroid tumor

Anatomy of the parathyroid glands:
The parathyroid glands are two pairs of small, oval-shaped glands located adjacent to the thyroid gland on each side of the neck.

Function of the parathyroid glands:
The parathyroid glands produce parathyroid hormone, which plays a role in the regulation of calcium levels in the blood. Precise calcium levels are important in the human body, since small deviations can cause muscle and nerve impairment.

Parathyroid hormone stimulates the following functions:

1. release of calcium by bones into the bloodstream
2. absorption of calcium in food by the intestines
3. conservation of calcium by the kidneys

What is a parathyroid tumor?
The parathyroid glands are located in the front of the neck near the thyroid gland. A parathyroid tumor or adenoma is a growth inside a parathyroid gland. The most common cause of primary hyperparathyroidism (see below) is a single benign adenoma that occurs in 1 of the 4 parathyroid glands. This is responsible for 75-85% of the disease. Enlargement of all four glands or hyperplasia occurs in 10-20% of patients. Multiple adenomas, in other words enlargement in two glands, occur in 3-8% of patients. Cancer is extremely rare as a cause of hyperparathyroidism and occurs in less than 1%.

What is hyperparathyroidism?
Hyperparathyroidism is a condition that occurs when there is too much secretion of parathyroid hormone. This causes the calcium level in the blood to be inappropriately high. Hyperparathyroidism occurs in three forms: primary, secondary and tertiary. Primary hyperparathyroidism occurs when the regulation of parathyroid hormone secretion by the feedback from the serum calcium is disturbed and the oversecretion of parathyroid hormone is not inhibited by the elevated calcium. Primary hyperparathyroidism is quite common and occurs in almost 0.1% of the population. It is seen most frequently in older women. It is the most common cause of hypercalcemia in non hospitalized patients.  Secondary hyperparathyroidism most commonly occurs in patients with chronic renal disease where the absorption of calcium from the intestine is impaired so that the parathyroid glands have to compensate and secrete more parathyroid hormone. Tertiary hyperparathyroidism occurs when the renal disease is corrected but the parathyroid hormone over secretion continues autonomously. The excess parathyroid hormone secretion acts to take calcium from the bony skeleton to increase the level in the blood. This causes generalized weakening of the bones from osteoporosis and osteopenia. The high calcium in the blood has to be excreted in the urine so kidney stones can often occur.

What are symptoms of a parathyroid tumor?
The classic symptoms of hyperparathyroidism include renal stones, painful bones, abdominal groans, psychic moans, fatigue, tiredness and hypertension. Many patients with hyperparathyroidism are thought to be asymptomatic but when questioned closely they will have muscle, bone and joint pain, acid reflux disease, increased thirst and frequency of urination, weakness, fatigue, depression, constipation and change in mood. Hyperparathyroidism can occur as an inherited problem and can be caused by prior exposure to radiation. In most patients we do not know why they develop this problem. Enlarged parathyroid glands are almost never able to be felt when examining the neck. If a lump is felt it is most often a thyroid nodule. Thyroid problems can occur frequently in patients with hyperparathyroidism and vice versa. So patients with hyperparathyroidism should be checked for thyroid disease and patients with thyroid disease should be checked for hyperparathyroidism.
The symptoms of a parathyroid tumor may resemble other conditions or medical problems. Always consult your physician for a diagnosis.

How is hyperparathyroidism diagnosed?
Hyperparathyroidism is diagnosed by blood tests. Measurement of serum calcium and parathyroid hormone are the means for this. The serum calcium level is almost always elevated and the parathyroid hormone level is inappropriately high for the level of calcium. There are other causes of elevated calcium but these are usually able to be identified when a doctor takes a complete history and physical examination. Surgery is indicated for all patients with symptomatic hyperparathyroidism unless their medical condition makes the risk of operation too high. Kidney stones, loss of bone density (osteoporosis) and muscle weakness have the best response to parathyroidectomy but even problems with depression, mood, weakness and loss of energy and stamina can be improved in many patients. Our research has shown this type of benefit in patients who have their hyperparathyroidism corrected with surgery.

After the diagnosis of hyperparathyroidism is confirmed, an attempt is made to identify and localize an enlarged parathyroid gland. The tests that are most useful for this are ultrasound of the neck which can be done in the office and nuclear medicine scan using technetium sestamibi .

Treatment for a parathyroid tumor:
Surgery to remove the tumor or enlarged glands is currently the only effective treatment for hyperparathyroidism.

If an enlarged parathyroid gland has been found on the sestamibi scan, ultrasound or both, a minimally invasive parathyroidectomy can be performed. Minimally invasive parathyroidectomy involves a small approximately an inch long incision in the neck over the enlarged parathyroid gland. This can be done under local or general anesthesia depending on patient preference. A skilled surgeon can find the enlarged gland and remove it quite safely. In order to be sure that the gland is the only cause of the hyperparathyroidism it is possible to measure parathyroid hormone levels during the operation. The levels should return to normal if all abnormal parathyroid tissue has been removed. If they do not, the surgeon will have to look for the remaining glands until the levels correct. This occurs only in a small minority of patients. The endocrine surgeons at the University of Miami have reviewed their results with parathyroidectomy using this minimally invasive approach and have shown it to be very effective.

In experienced hands parathyroidectomy is a very safe operation. There is really no risk of infection or need for blood transfusion. There is a 1 in 100 to 1 in 1000 chance of being hoarse after the operation and an equally small risk that the patient will have to take medicine to control their calcium metabolism since some patients can develop very low blood calcium. This is usually because their bones now will try to replace all the calcium that has been lost over time.

Rarely an abnormal parathyroid gland can be located in the chest. This can be removed with thoracoscopy in many patients so a large incision is again avoided. Thoracoscopy is done by making small incisions between the ribs so that a scope with a camera and instruments to dissect and remove the parathyroid glands can be put into the chest. This method is much less painful and allows the patient to return to their normal activity much quicker.

Secondary hyperparathyroidism requires removal of all of the parathyroid glands since they are all overactive. The parathyroid glands can be transplanted to the muscle in the forearm so that normal parathyroid function can be maintained. Parathyroid tissue can also be frozen and re-transplanted when it is thawed at a later date if the patient needs more parathyroid tissue.

THE THYROID GLAND

Anatomy of the thyroid gland
Functions of the thyroid gland
What are thyroid nodules?
What are thyroid adenomas?
What are cancerous thyroid tumors?
What are the different types of thyroid cancer?
Diagnosis of thyroid cancer
Treatment for thyroid cancer

Anatomy of the thyroid gland:
The thyroid gland is located in the front of the neck, below the larynx (voice box). The small, two-inch gland consists of two lobes, one on each side of the windpipe, connected by tissue called the isthmus.

The thyroid tissue is made up of two types of cells: follicular cells and parafollicular cells. Most of the thyroid tissue consists of the follicular cells, which secrete iodine-containing thyroid hormones called thyroxine (T4) and triiodothyronine (T3). The thyroid needs iodine to produce these hormones. The parafollicular cells secrete the hormone calcitonin.

Functions of the thyroid gland:
The thyroid plays an important role in regulating the body’s metabolism and calcium balance. The T4 and T3 hormones stimulate every tissue in the body to produce proteins and increase the amount of oxygen used by cells. The harder the cells work, the harder the organs work. The calcitonin hormone works together with the parathyroid hormone to regulate calcium levels in the body.

Levels of the T4 and T3 hormones secreted by the thyroid are controlled by the pituitary gland's thyroid-stimulating hormone (TSH), which in turn is controlled by the hypothalamus.

What are thyroid nodules?
Thyroid nodules or lumps are very common. As many as 5% of the North American population may have a thyroid nodule. When a nodule is felt in the neck a concern is raised about the possibility of cancer. However, most nodules are not cancer. Other causes for these nodules include cysts, thyroiditis, nodular goiter, adenomatous nodules, follicular adenomas and Hürthle cell adenomas. All of these conditions are benign. Even though as many as ten million people in the United States may have a palpable thyroid nodule there are only about 26,000 new thyroid cancers diagnosed every year. Most thyroid cancers are able to be treated and are not a real threat to the patient if they are managed appropriately. When a thyroid nodule is found the first step is for a doctor to take a detailed history from the patient. Most nodules that occur between the ages of 30 and 50 are benign. When nodules occur in the very young or very old there is a greater worry about the possibility of cancer. Benign nodules are more common in both men and women but nodules are five times more frequent in females. Therefore the proportion of malignant nodules in males is twice that of females.

One of the most important aspects is whether a patient has received prior radiation to the head and neck area. This has been clearly associated with an increased risk of both benign and malignant nodules. The patient with a solitary nodule that has had prior radiation exposure the prevalence of cancer is 30-50%. If there is a history of other endocrine problems such as pheochromocytoma or hyperparathyroidism the patient may have a multiple endocrine neoplasia syndrome which increases the possibility of thyroid cancer.

What are thyroid adenomas?
Thyroid adenomas grow from the cell layer that lines the inner surface of the thyroid gland. The adenoma itself secretes thyroid hormone. If the adenoma secretes enough thyroid hormone, it may cause hyperthyroidism. Thyroid adenomas may be treated if they cause hyperthyroidism. Treatment may include surgery to remove the part of the thyroid with the overactive nodule.

What are cancerous thyroid tumors?
A nodule that has been stable in size for years is almost always benign. Rapid development of a nodule would suggest a cyst or a hemorrhage. Thyroid cancer usually develops over weeks or months. If there is difficulty swallowing, speaking or breathing these symptoms are more worrisome for thyroid cancer. Nodules that are hard when felt during the examination and that are fixed to surrounding tissue such as the muscles of the neck are more likely to be cancerous.  The presence of a single nodule is more likely to be associated with a cancer diagnosis.  Cancer of the thyroid occurs more often in people who have undergone radiation to the head, neck, or chest. However, most thyroid cancer can be cured with appropriate treatment. Thyroid cancer usually appears as small growths (nodules) within the thyroid gland. The symptoms of thyroid cancer may resemble other conditions or medical problems. Always consult your physician for a diagnosis.

What are the different types of thyroid cancer?
The National Cancer Institute (NCI) describes the major types of thyroid cancer as follows:

1. Papillary and follicular variant of papillary thyroid cancers.  These two types of thyroid cancer account for 80 percent to 90 percent of all thyroid cancers. Papillary thyroid cancer is the more common of the two types. Both types begin in the follicular cells of the thyroid and tend to grow slowly.

2. Follicular thyroid cancer.  This type of thyroid cancer occurs most often among elderly patients and accounts for about 15 percent of thyroid cancers. This type of thyroid cancer is more aggressive and tends to spread through the bloodstream to other parts of the body.

3. Medullary thyroid cancer.  This type of thyroid cancer accounts for 5 percent to 10 percent of all thyroid cancers. Medullary thyroid cancer is the only thyroid cancer that begins in the C cells. This type of thyroid cancer is easier to control if it is found and treated early, before it spreads to other parts of the body. There are two types of medullary thyroid cancer: sporadic medullary thyroid cancer and familial medullary thyroid cancer (FMTC). Because familial medullary thyroid cancer tends to run in families, screening tests for genetic abnormalities in the blood cells may be conducted.

4. Anaplastic thyroid cancer.  This rare type of thyroid cancer accounts for about 1 percent to 2 percent of all thyroid cancers. Anaplastic thyroid cancer begins in the follicular cells and tends to grow and spread very quickly.

Diagnosis of thyroid cancer:
Most blood tests are normal in patients with a solitary thyroid nodule. Blood studies to measure thyroid function can determine if the patient has a hyper or overactive thyroid or a hypo or under active thyroid. The best test for doing this is measurement of thyroid stimulating hormone or TSH. TSH is low in hyperthyroidism and high in hypothyroidism.

There are a number of ways that the thyroid gland and the nodule can be visualized radiologically. One is ultrasound of the neck. This can be done in the office and can show if a nodule is present and whether it is solid or cystic by passing sound waves from a transducer through the neck and back to the transducer. A thyroid scan can show if a nodule functions like normal thyroid tissue. It does this because the thyroid takes up a radio labeled isotope preferentially. This can be measured with a gamma counter which is like a Geiger counter. If the thyroid nodule does not function it is called cold. If it functions more than normal tissue it is called hot. Hot nodules are almost never malignant. Cold nodules may harbor cancer but most do not.

The best way to diagnose the nature of a nodule is to do a fine needle aspiration biopsy (FNA). This is an office procedure that uses the same needles for drawing blood to take some cells from the thyroid nodule. These can be looked at under the microscope by a cytologist. The cellular features can be used to confirm that the nodule is benign, to diagnose a cancer, or to diagnose a follicular neoplasm. This latter diagnosis is really indeterminant because the cells of a benign follicular tumor and a malignant follicular tumor look quite the same and the whole tissue has to be examined under the microscope to determine whether a cancer is present.

Small nodules that have been diagnosed benign by fine needle aspiration biopsy do not usually require surgery. Surgery is the preferred treatment for thyroid nodules that are cancerous, suspicious for cancer or are non cancerous but large enough to cause symptoms such as difficulty breathing or swallowing. Enlargements of the thyroid that have moved down into the chest are called substernal goiters. These should be removed because they often cause symptoms and are very difficult to be sure they are not increasing in size since they cannot be felt. People who have thyroid nodules after having had radiation exposure to the head, neck or chest should also undergo surgery because of their high risk of having thyroid cancer. Most thyroid cancers grow and spread slowly so that delaying surgery a short time for a suspicious nodule does not really pose a health risk for the patient. If there is a delay it is a good idea to take thyroid hormone replacement to put the thyroid gland at rest. Taking these pills replaces the normal thyroid function and avoids stimulation to the growth of the thyroid or the nodule. Thyroidectomy can also be used to treat hyperthyroidism.

Summary:
In addition to a complete medical history and physical examination, diagnostic procedures for thyroid cancer may include:

1. blood tests - to evaluate the level of thyroid-stimulating hormone (TSH), calcium, calcitonin (a hormone produced by normal C cells of the thyroid gland), and other substances in the blood such as thyroglobulin.

2. thyroid scan - a type of nuclear scan that examines the thyroid after a person is given (by mouth or intravenously) a small amount of radioactive material that contains iodine or technetium. For a short period, the radioactive material emits radiation. A special camera, called a gamma camera, is used to determine the amount of radiation that has been absorbed by thyroid nodules. Cold nodules are nodules that absorb less radioactive material than the surrounding thyroid tissue. Whereas, hot nodules are nodules that absorb more radioactive material.

3. ultrasound (Also called sonography) - a diagnostic imaging technique that uses high-frequency sound waves and a computer to create images of blood vessels, tissues, and organs. Ultrasounds are used to view internal organs as they function, and to assess blood flow through various vessels.

4. biopsy - a procedure in which tissue samples are removed (with a needle or during surgery) from the body for examination under a microscope to determine if cancer or other abnormal cells are present. 

Treatment for thyroid cancer:
Thyroid surgery is most often done under general anesthesia although it can be done under local. The operation is done through a small incision made in the lower neck. This area of the body heals quite well and often these incisions cannot even be seen when they are healed. The muscle and other tissue are separated to expose the thyroid gland. A total lobectomy and isthmusectomy is the minimum procedure that is recommended if there is a nodule in one lobe of the thyroid. The isthmus is the narrow band of tissue connecting the two lobes of the thyroid. Removed tissue is always examined under a microscope to determine whether cancerous cells are present. If cancer is present the surgeon will usually perform a total thyroidectomy. In this operation the entire gland is removed. This is done when the thyroid gland contains cancer or when there is a high risk of developing thyroid cancer or when there are nodules in both lobes of the thyroid. If the patient does have cancer and it has spread to the lymph nodes, these lymph nodes are removed with a procedure called a neck dissection. The lymph nodes in the center part of the neck are removed with a central neck dissection. The lymph nodes in the lateral part of the neck are removed with a modified neck dissection that preserves the muscle and vessels and nerves in that part of the neck.

Many patients can go home on the day of their surgery if they have only had a lobectomy. For a total thyroidectomy most patients should stay overnight until they have recovered from their anesthesia and operation. Patients usually return quite quickly to their normal activity after thyroid surgery. Thyroid surgery is generally quite safe. There are some very special risks associated with it. Hoarseness and change of voice can occur because the nerves that go to the voice box or larynx lie at the back of the thyroid gland. It can be damaged during thyroid surgery. The more experience your surgeon has the less risk there is.

Summary:
Specific treatment for thyroid tumors will be determined by your physician based on:

• your age, overall health, and medical history
• extent of the disease
• your tolerance for specific medications, procedures, or therapies
• expectations for the course of the disease
• your opinion or preference

Treatment may include one or more of the following:

1. surgery - to remove all or part of the thyroid. Types of thyroid surgery include:

2. • total thyroidectomy – removal of the entire thyroid and sometimes the nearby lymph nodes.
   • lobectomy - removal of the lobe with the cancerous nodule. The nearby lymph nodes and part of the remaining thyroid tissue may also be removed.
   • Modified neck dissection - the removal of cancer involved lymph nodes in the lateral neck saving muscles, nerves and blood vessels.
     
3. radioactive iodine therapy (also called radioiodine therapy) - a treatment in which small amounts of radioactive iodine (I-131) is given (usually in a capsule or liquid) to destroy any normal thyroid or cancer cells, that have not been removed by surgery or have spread to other parts of the body. Radioactive iodine therapy is usually not used to treat medullary or anaplastic thyroid cancer.
   
4. external radiation (external beam therapy) - a treatment that precisely sends high levels of radiation directly to the cancer cells. The machine is controlled by the radiation therapist. Since radiation is used to kill cancer cells and to shrink tumors, special shields may be used to protect the tissue surrounding the treatment area. Radiation treatments are painless and usually last a few minutes. This has a very limited role for most thyroid cancers.
   
5. thyroid hormone therapy - hormones are given to prevent, slow, or stop cancer cells from growing. Hormone therapy as a cancer treatment inhibits or blocks any stimulating substances such as TSH that would promote the growth of the thyroid cancer. Thyroid hormone therapy may be used to treat papillary and follicular thyroid cancer. This therapy may also be necessary after surgery or radioactive iodine therapy to replace the natural or body’s own production of thyroid hormone.
   
6. chemotherapy - the use of anticancer drugs to treat cancerous cells.  In most cases, chemotherapy works by interfering with the cancer cell’s ability to grow or reproduce. Different groups of drugs work in different ways to fight cancer cells. The oncologist will recommend a treatment plan for each individual. This has a very limited role for most thyroid cancers.