I am set to have surgery for primary hyperparathyroidism in the near future. So far testing has not been able to detect the location of a hyperparathyroid tumor. I have been told that during the exploratory surgery if the parathyroid glands cannot be located, my thyroid will be removed in an attempt to lower calcium levels. I was also told that if a tumor appeared in the future additional surgery would be necessary. I would like to know if the removal of a thyroid is the normal course of action when parathyroid glands cannot be located.
Thanks for writing. The short answer is that removing the entire thyroid is almost never necessary in parathyroid surgery, but occasionally removing a piece of thyroid can help.
There is one very specific scenario in which I will remove a piece of thyroid. Here is the scenario: I am performing an operation for primary hyperparathyroidism and have found three normal parathyroid glands, but I’m missing an inferior parathyroid gland. I have to assume that the tumor is in this inferior gland. None of the preoperative imaging has shown any tumors in unusual (or ectopic) locations. The missing inferior parathyroid gland may be inside the thyroid or in the thymus (the thymus is a separate organ that goes from your neck down to your chest). If I don’t see the tumor within thymus, then my best guess is that this missing gland is within the lower third of the thyroid gland. And in this situation, it makes sense to remove the lower third of that thyroid lobe, on the side of the missing parathyroid (if you are missing the left inferior parathyroid, then you remove the lower portion of the left thyroid lobe). If the parathyroid tumor is within that part of the thyroid, you will be cured, because the tumor will be removed. Note that I only do this if I have seen the other parathyroid glands, and I’m sure that those glands are not causing parathyroid disease.
This is not a very common scenario, but it does happen. I would be concerned, though, if your surgeon wanted to remove the entire thyroid or even an entire lobe for a missing parathyroid. This is a larger procedure that will increase the risks of the operation, and is not guaranteed to cure you. It can also put the normal parathyroid glands at risk, since a normal gland can also be stuck on the thyroid.
Your surgeon also mentioned the possibility of future operations. While this can also be true, most patients can be cured with one operation, as long as all of the glands are visualized. If the glands are not seen, then yes, you can miss a small parathyroid tumor, which will need to be removed later.
To give yourself the best chance of cure, you want to find an experienced parathyroid surgeon. If your surgeon is not usually able to identify all four parathyroid glands, then you may want to consider seeing someone more experienced.