Parathyroid Surgery with Denise Carneiro-Pla, M.D.

Surgery on any part of the endocrine system has the best results when performed by a highly experienced endocrine surgeon, according to recent studies. In this episode of Advance with MUSC Health, Denise Carneiro-Pla, M.D., explains the endocrine disease surgeries — specifically parathyroid surgery — she and her colleagues offer.

"Parathyroid surgery requires a combination of skills to try to do these procedures with the least amount of risk and complications. And that's what experienced surgeons like endocrine surgeons have to be able to provide … You should always look for a specialized endocrine surgeon that does a lot of these procedures, so you can have a good outcome."
— Denise Carneiro-Pla, M.D.

Topics Covered in This Show

• Dr. Carneiro-Pla is one of two endocrine surgeons at MUSC Health focused on taking care of thyroid and parathyroid disease as well as adrenal diseases.
• Surgery on the parathyroid glands is a major focus of Dr. Carneiro-Pla. These glands are located behind the thyroid and are responsible for calcium metabolism.
• When parathyroid gland function is abnormal, it can cause osteoporosis and kidney stones.
• Patients with parathyroid disease that present high levels of calcium and high parathyroid hormone (PTH) should be surgically evaluated by an endocrine surgeon.
• The conditions that can cause hypoparathyroidism are hyper-functioning tumors that produce too much hormone and increase calcium levels, multiple endocrine neoplasia, lithium induced hypoparathyroidism, patients with renal failure and patients that are on dialysis. Although these are operated in this single group of glands, they are treated differently.
• The steps before surgery include: evaluation, imaging, discussing the risks and benefits of the surgery and making sure that their heart is OK for general anesthesia.
• If surgery is minimally invasive and a patient is one of the 85 percent of patients to have only one gland removed, calcium supplementation is needed post surgery but is not a long term. The more glands that were removed in surgery sometimes require longer calcium supplementation.
• When looking for a surgeon, you should look for someone who has a 98 to 99 percent success rate of correcting the calcium levels within six months from that procedure.
• Carneiro-Pla follows her patients' bloodwork for the rest of their lives and will bring them back if they have any issues.
• Not every elevation of the parathyroid hormone means surgery is needed. For example, patients that have low vitamin D may have test results showing high PTH and that may not be abnormal.

Read the Show Transcript

Erin Spain [00:00:04] Welcome to Advance with MUSC Health. I'm your host, Erin Spain. This show's mission is to help you find ways to preserve and optimize your health and get the care you need to live well. Diseases of the endocrine system may require surgery on the neck or abdomen to access thyroid or adrenal glands. Studies show having a highly experienced endocrine surgeon can help reduce complications during and after surgery. Here at MUSC Health, Dr. Denise Carneiro-Pla, is part of a team of board certified surgeons who specialize in endocrine surgery. She joins me today to talk about the endocrine system and specifically parathyroid glands and the surgical care she offers patients with parathyroid disease. Welcome to the show.

Denise Carneiro-Pla, M.D.[00:00:53] Thank you, Erin. Thank you for inviting me.

Erin Spain [00:00:55] Well, tell me about your work as an endocrine surgeon and explain the diverse group of endocrine surgeons at MUSC Health.

Denise Carneiro-Pla, M.D.[00:01:03] The endocrine surgery here at MUSC is made of two endocrine surgeons, myself and a Dr. Bernice Wong, who is my new partner. And we together take care of thyroid and parathyroid disease as well as adrenal diseases. And we have a group of multidisciplinary management of these patients where we have endocrinology, psychopathology, pathology and radiology that we all work together in delivering care for patients with endocrine surgical diseases.

Erin Spain [00:01:30] And you specifically have specialize in parathyroid disease and parathyroid surgery. First of all, just tell me about parathyroid glands. Where are they located in the body? And then just tell me a little bit about parathyroid disease and how it's diagnosed.

Denise Carneiro-Pla, M.D.[00:01:45] So I have been dedicated in research of parathyroid disease for many years, since the beginning of my career. When I was in Brazil, I decided to come to this country to do some research in parathyroid disease. There's a very special place in my heart for parathyroid. So the parathyroid are these little glands that are located behind the thyroid on the neck, sort of right interior to the windpipe. And those little glands are responsible for your calcium metabolism. It can cause a lot of symptoms when they are abnormal, but they also can cause osteoporosis and kidney stones. So patients with parathyroid disease often have also findings in bloodwork where the calcium is elevated, as well as the parathyroid hormone. And patients with that presentation of high calcium, high PTH often should be surgically evaluated by an endocrine surgeon.

Erin Spain [00:02:32] Tell me about the different diseases that are involved with the parathyroid glands.

Denise Carneiro-Pla, M.D.[00:02:37] So the parathyroid can become tumors, hyperfunctioning tumors that produce too much hormone. Therefore, your calcium will be elevated for several reasons. The primary hypoparathyroidism, which is a disease of the parathyroid zone, the normal person will see their doctor usually have a bloodwork that shows a high calcium or have symptoms that trigger the doctor to measure the calcium in the parathyroid hormone, the parathyroid disease can also come from a familial disease, which is a different syndrome. There's a multiple endocrine neoplasia, one and two or isolated familial hypoparathyroidism, which is a little bit of a different disease. Lithium induced hypoparathyroidism is a different kind of disease of the parathyroid that is also treated differently, as well as patients with renal failure. Patients that are on dialysis have parathyroid disease that is spread in a different way. So all these different conditions can cause hypoparathyroidism. And although we operate in this single group of glands, they have different sources and different etiologies and they're treated differently.

Erin Spain [00:03:37] So when patients end up seeing you and they're with you in an exam room, what have they gone through at this point and what are they looking for when they come to see you for a surgery consultation?

Denise Carneiro-Pla, M.D.[00:03:47] So most patients that end up coming to see us in endocrine surgery, they already had some blood work done with their doctors where the calcium was elevated and usually have a parathyroid hormone also measures called PTH. And if those two numbers are elevated they end up seeing me. So when a patient comes to see us, we evaluate any symptoms they may have, any findings on bone density, if they have any indications for surgery, which could be symptomatology, usually bone pain, joint pain, memory loss or difficulty concentrating. They can have kidney stones, they can urinate a lot night. The patients are usually very tired. So those are the symptoms that indicate surgery. In the lab work. We see the calcium in the PTH level as well as kidney function. And if we have a bone density, we evaluate to see if there's any bone loss associated to this disease. And so we make decisions about this disease being a reason for surgery or not. So one thing that we have think is very good about our center in the research center here at MUSC, I like to call a one stop shop. You know, usually the patient comes to me with the blood work when you come, repeat what you had done. And they usually do an ultrasound on every patient that I see. And on the ultrasound a majority of the times about 90 percent of the times I can see a parathyroid and if I localize the parathyroid gland without question, usually that's enough for me to recommend surgery and have you schedule. So at times this imaging is not as clearly identified and I don't feel comfortable in taking the patient to the operating room with just that. Often we can get, the same day, for DCT, which is another imaging that we do for localizing parathyroid. And occasionally we need to do another imaging which is a sestambibi scan, is a nuclear study that help us to find parathyroid. The reason we go to all this lens to try to localize parathyroid is because the best localization I have, the easier the procedure is, the less dissection I do. And my goal is to always try to treat patients with minimally invasive parathyroidectomy, the minimal amount of dissection to preserve this glands that when they are normal, they are also helping to build your bone. So we need to preserve the parathyroid. They're normal and only remove the bad ones. The majority of the times the abnormal glands are only one, maybe two in about 15 percent of the cases. So this can often be done with a very minimal invasive approach.

Erin Spain [00:06:08] Are there ever patients who want to take a wait-and-see approach when they find out that, yes, there is a growth on one of the glands and you do recommend surgery. How does that typically work? Are most patients ready for surgery right away?

Denise Carneiro-Pla, M.D.[00:06:20] So some patients do not want to, you know, go through with surgery. And if you don't have any, I call it hard indication, your bones are not presenting with osteoporosis. You're not having a higher urinary calcium that could cause your kidney stones and your calcium is not greater than 11.2 or one milligram per deciliter above normal range, or your kidney function is not decreased because this makes the kidney function worse. You could wait, you know, until you observe, but it tends not to get better and eventually you need an operation. So we discuss the risks and benefits of surgery. And if the procedure will be straightforward and a lot of that comes from imaging, I tend to recommend reconsidering and may be undergoing surgery.

Erin Spain [00:07:02] So what steps to patients need to take before surgery?

Denise Carneiro-Pla, M.D.[00:07:06] So first we do all this evaluation, we just discuss and we do the imaging. We discuss extensively the risks and benefits of the surgery. And with this the usual preoperative evaluation. We make sure their hearts are OK for general anesthesia. You know, the patients have a couple medications they cannot take before surgery. If somebody had a previous neck surgery, usually on the ultrasound, we'll look at their vocal cords, which need to be functioning appropriately before the procedure. And I can usually do that in clinic as well. Occasionally we need to ask a provider colleague. They can look at the vocal cords with this scope. But the majority of the times it's pretty straightforward from the time we see each other and to the morning of the surgery.

Erin Spain [00:07:44] So after surgery, how long until patients start to feel better and some of these symptoms start to dissipate?

Denise Carneiro-Pla, M.D.[00:07:51] Actually, the results of the surgery are usually noticed pretty quickly. The majority of the patients to have this fogginess that they cannot concentrate sometimes they tell me, is like a fog was lift in the recovery room and the bone pain also go away immediately. Some patients don't do so well with general anesthesia, so it takes a little longer for them to feel better. But fatigue and, you know, lack of energy resolves a lot and many, many patients. Right in the first week after surgery.

Erin Spain [00:08:18] What about after surgery then? Are there certain medications or supplements that patients have to take or do they have ongoing interaction with you?

Denise Carneiro-Pla, M.D.[00:08:25] So we do see each other about a week after the surgery, and I usually put my patients on calcium and it depends what kind of surgery you do. That's why it's so important to prepare you appropriately. So here at MUSC, the way I do the surgery and so does my partner, we try to do this as a minimally invasive surgery, as I mentioned, and we measure your parathyroid hormone during the surgery. Truly intraoperative. A lot of places they measure the PTH, but they look at it later, not at the time you're in the OR. So while you're in the operating room, we put an arterial line, which is a little artery that we get on your wrist and we draw blood during the surgery to measure your parathyroid hormone. The half-life of the PTH is very short, which is about five minutes. So after we took the parathyroid gland that is abnormal, you expect the hormone to drop pretty quickly after. In about 10 minutes we make a decision if that is the only gland that is the cause of your high calcium or if we need to go further. So if your surgery is quite minimally invasive and you are one of the 85 percent of patients to have only one gland, usually that's pretty straightforward calcium you take that I ask you to keep taking for a little while, but is not a long term. The more aggressive we are, the more glands that were removed, sometimes that requires longer calcium supplementation. It depends how your parathyroid function is after the surgery. Sometimes I will put you on calcium and high dose for quite some time to prevent this from coming back.

Erin Spain [00:09:53] Why is it important that patients seek out experienced surgeons like you and MUSC Health which has really the gold standard of care for parathyroid surgery.

Denise Carneiro-Pla, M.D.[00:10:04] So parathyroid procedures are very well linked to the experience of the surgeon, the outcomes of those procedures. If you don't do this parathyroid very often, there's plenty data published about this. If you don't do this procedure very often, the chance of you having a failed surgery or having a complication like nerve injury that can change your voice is definitely a lot higher. That's even more significant for thyroid surgery. But parathyroid surgery requires like a combination of skills to try to do these procedures with the least amount of risk and complications. And that's what experienced surgeons like endocrine surgeons have to be able to provide. So does that matter where you live in the country? You should always look for a specialized endocrine surgeon that does a lot of these procedures. So you can have a good outcome. The success rate of this procedure in my hands is about 98%. And that's where you should look for something 98, 99 percent chance of correcting the calcium within six months from that procedure.

Erin Spain [00:11:03] You are not only a surgeon, you're a physician scientist. You're also studying this disease. Tell me a little bit about your research and what makes you want to learn more about this disease and how to treat it.

Denise Carneiro-Pla, M.D.[00:11:15] To me, parathyroid glands are fascinating. These are fascinating tiny little glands. We cannot live without them. And we also need to have them to do the functions that keeps our calcium normal or bone health, you know, in check. And make sure you continue building bones, especially as this group of patients are older women. So this is very important. My passion for parathyroid disease came when I was in Brazil after I was trained surgeon there, I did some research, the intraoperative PTH and the dynamics of the hormone, which I've actually learned even further when I came to Miami to work with Dr. Irvin. Dr. Georgie Irvin is the father of the intraoperative PTH. His research and his working with companies to make the PTH faster, he changed single handedly what we do as endocrine surgeons. And I had the pleasure of working with him for 10 years and continue working with him to this day to study this. So by the time I got to Miami, which was about 25 years ago, he was writing a lot about this changing the management of parathyroid and how the dynamics of the hormone works during the procedure. And so I had the single opportunity, amazing opportunity of my life to be part of that development of the practice in management of parathyroid disease. So we have written a lot over the years about parathyroid management intraoperatively for primary hypoparathyroidism. And I still learn to this day, you know, I follow my patients forever with bloodwork for the rest of their lives, and I usually see them and bring them back if they have any issues, you know, and it teaches me a lot about the surgery and makes me an active researcher in endocrine surgery, especially in the realm of parathyroid disease.

Erin Spain [00:12:58] Is there anything else you want to add that we didn't cover that you think is important to share?

Denise Carneiro-Pla, M.D.[00:13:02] I think it is important for the patients to understand that at times the parathyroid is over functioning to correct something that is abnormal. Not every elevation of the parathyroid hormone means that they need a surgery. So a very common reason for that is vitamin D deficiency. So patients with low vitamin D, we have a high PTH and this PTH is not abnormal. There's no disease of the parathyroid. They're just doing their job. So when the parathyroid loses the feedback and they start becoming tumors. That's the time when the endocrine surgery comes in and usually the calcium levels are elevated at that time. So not every elevated PTH actually requires surgical treatment. And sometimes patients here, especially, we're hearing all these great things that you can feel with a parathyroid surgery. They want to take their parathyroid out, and parathyroid should only be removed when it's proved to be abnormal. And usually that is associated with high calcium. And there's other conditions that can do that. Kidney dysfunction can do that on its own and high urinary calcium that can be caused by urinary calcium leak. So all those things need to be worked up and treated first before you go to a procedure. I think this is something that is often misunderstood and we discuss these things extensively when I see the patients in clinic.

Erin Spain [00:14:21] What do you do to optimize your health and live well?

Denise Carneiro-Pla, M.D.[00:14:25] You know, you got to find time for self-care and although I would be a lot better at it, I think the self-care and get out and go in the green area and walk, you know, go hike or go to the beach. You know, me and my family, we like to go hunt for shark teeth fossils and we love to do that. And that's what I would say is my self-care moment and that's what we do for fun.

Erin Spain [00:14:49] Well, thank you so much for coming on the show and talking about your work and you are so passionate about it. It's easy to tell that this is something that you really thrive by helping these patients. So, thank you so much for your time today.

Denise Carneiro-Pla, M.D.[00:15:01] Thank you so much for having me.

Erin Spain [00:15:07] For more information on this podcast, check out advances in U.S. Health data work.