Some parathyroid adenomas (benign tumours) are easy to find and some are difficult to find. Over 80% of parathyroid disease is caused by a single tumour the rest is comprised mainly of more than one adenoma or hyperplasia where all four glands are swollen but there is technically no tumour.
The easiest case for surgery is a single parathyroid tumour, which is positioned close to the surface of the neck because they often show up on both an ultrasound and a sestamibi scan which gives your surgeon a 3D position in space (where and how deep). Single adenomas which are not close to the surface are unlikely to show up on an ultrasound scan (like mine). Another problem with deeper tumours is that they are usually hidden behind muscle and thyroid tissue and so the radiation they emit can get lost in the background and may not show up as well on a sestamibi scan (as in my case).
The scan of my tumour (despite being 2cm in size) only showed (in the words of my surgeon) a ‘faint and not very convincing hot spot’. You can see the slight glow North North West of the end of the arrow. SSN (as seen on the scan) is an anatomical term, it stands for Supra-sternal Notch – this is the dip in your neck just below the Adams apple – the ‘thinnies’ amongst us will have more of a pronounced dip. As I am a bit of a porker these days, I don’t have an obvious SSN unless you poke me below the Adams apple! Pointing out the SSN on the scan just allows the surgeon to relate the scan to the patient in from of him, so he can mark them up with his magic marker before he starts cutting
Looking at my sestamibi scan (click the scan for a bigger picture), you can see exactly what he means – it didn’t exactly glow like a Roman Candle!
Other things to point out for anyone who hasn’t seen their own sestamibi scan: The butterfly shaped glow in the neck is the thyroid, the 2 bright spots under the chin and the 2 either side of the cheeks are the salivary glands. The radioactive isotope they give you likes to pool in the salivary glands!
My Parathyroid Sestamibi Scan
Because my elevated blood calcium & inappropriately elevated PTH showed I with little doubt had parathyroid disease, my surgeon still operated with a negative ultrasound and weak sestamibi. The decision to operate is always based on blood chemistry and not on a negative or positive scan result. Scans are simply tools to allow the surgeon to locate the tumour so he is less likely to have to poke around playing a game of hunt the parathyroid tumour.
If your surgeon will not operate with negative scans, find another competent and confident surgeon.
A weak scan result will often result in the surgeon doing a full collar incision – a very conservative 5cm in my case, so they can check all 4 glands for disease. One benefit of having all four checked whilst your under is that there is less chance of a second tumour being missed and having to be operated on further down the line.
Parathyroid glands can be found in odd places rather than the usual 2 superior (upper) and 2 inferior (lower) either side of the thyroid gland.
When we are embryos in the womb, the parathyroid glands can sometimes accidentally hitch a ride with other organs. Most commonly, the upper glands can get mixed up with the salivary glands and end up under the jaw or the lower ones can travel down with the thymus (a gland involved in the immune system) to the upper chest area.
Generally a surgeon will find them where he expects them, but because they can be awkward to find, you want a surgeon who knows exactly what he is doing!
Whilst your surgeon is poking around (sorry I mean carefully dissecting) in your neck he may find it useful to use a dye, particularly if he’s trying to find all four glands – remembering that normal glands are the size of a grain of rice!
Methylene blue is the parathyroid surgeon’s best friend, simply take the recommended amount of methylene blue dye, add it to a 500ml bag of saline and attach the drip to the patient. Wait for half an hour for the bag to empty and voilà, one patient with bright blue parathyroid glands.
Some patients can end up with a slightly pale blue face or ‘whites of the eyes’ (completely reversible) – fortunately this didn’t happen to me.
The funniest and most entertaining part of having methylene blue pumped into your veins is the bright blue colour of your urine afterwards. I’m still peeing the stuff out now (though not as dark as the picture), almost 7 days after surgery. It did irritate my bladder for the first 12hrs after but that subsided quite quickly.
I couldn’t resist taking a picture for the blog. Those of a weak constitution, please look away now!
Methylene Blue UrineFor more information and to chat with others about High Blood Calcium/Primary Hyperparathyroidism/Parathyroid Problems click the image above to go to the Parathyroid Forum!