This case involves a patient who presented with hypercalcemia and was ultimately diagnosed with hyperparathyroidism. A sestamibi scan shows a parathyroid adenoma of the “posteroinferior aspect of the left thyroid lobe.” Some months later, surgery unsuccessfully located the problematic hyperparathyroid glands, despite positive visualization on the earlier scans. Nevertheless, the upper two glands were removed because biopsies showed they are 99% hypercellular. The Plaintiff continued to be hypercalcemic post-surgery. Despite this, additional surgeries were undertaken to remove the remaining glands. Surgery had no positive effect on the patient’s condition, and it is alleged that the glands did not need to be removed.
Question(s) For Expert Witness
- 1. Is there a requirement for removal upon discovery of 99% hypercellular activity, especially if that's not what surgery was initiated for?
Expert Witness Response E-022786
I perform between 2-4 thyroid/parathyroid surgeries per week in my practice. Hypercalcemia can be caused by many conditions, among them primary hyperparathyroidism. In primary hyperparathyroidism, most patients have a single diseased parathyroid – called a parathyroid adenoma. In some more rare cases, you can see a double adenoma (two distinct neoplasms). Another distinct entity is “four-gland disease”, in which there is hyperplasia of all four parathyroid glands. This is commonly associated with kidney failure, but is also seen in some genetic conditions and sometimes sporadically. The pathologist is often unable to differentiate parathyroid adenoma from parathyroid hyperplasia, which is why the success of surgery is often dependent on the biochemical resolution of the elevated PTH. Intraoperative PTH monitoring is commonly used as a way to differentiate the possibility of multiple diseased parathyroids over a single adenoma, and is used as an adjunct to frozen section. It is certainly reasonable to identify and biopsy all four glands in there is no improvement in intraoperative PTH levels after the initial parathyroid is removed. In general if a frozen section was performed and shows “hypercelullar parathyroid” than in most cases that parathyroid should be removed. The indications for re-operative parathyroid surgery are dependant on the labs. If there is unresolved hypercalcemia, surgery may be warranted.