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Joey Wahler (Host): Well, fake news, it's a phrase that's become commonly used in recent years as you know. But today, we're not talking about politics, but rather parathyroid hormone fake news. So we're discussing parathyroid disease misconceptions, separating fact from fiction.

Joey Wahler (Host): Welcome to MD cast by Tampa general hospital, a go-to listening location for specialized physician to physician content and a valuable learning tool for world-class health care. I'm Joey Wahler.

Our guest, Dr. Douglas Politz, parathyroid surgeon at Tampa General Hospital and the co-founder of the TGH Parathyroid and Thyroid Institute. Dr. Politz, thanks so much for joining us.

Dr Douglas Politz: Hey, great to be here. Thank you so much. This is one of those diseases that most people don't even know they have parathyroid glands, much less that something can go wrong. You can get a tumor of it. It can actually make you ill. So this is a great awareness move on Tampa General's part to get this word out.

Joey Wahler (Host): So simply put, for those unfamiliar, what is the parathyroid gland and how does disease there develop?

Dr Douglas Politz: Well, parathyroid glands, there are four of them. There are two on each side in the neck and we're not talking about a biblical disease. This is not 2000 years old. The first operation for parathyroid disease, for instance, wasn't until 1925. So we're right at about a century of even knowing about these, but they control your calcium level in your blood and that's all they really do. They monitor the calcium level in your blood minute to minute and make parathyroid hormone in response to it. And the parathyroid hormone, simply put, it will go and remove calcium from your bones, bring the calcium level in the bloodstream up. It will allow your intestines to get better at pulling calcium out of your diet and putting it in the bloodstream. And it alters the way your kidneys handle the calcium load that goes through the kidneys. And just in a nutshell, that's what the parathyroid glands do.

Joey Wahler (Host): And there are dangers if your calcium levels aren't where they should be. Tell us about those.

Dr Douglas Politz: The big problem is when someone has too high of a calcium level. When your calcium level goes too high, it's almost always indicative of a tumor of one or more than one of the parathyroid glands. And so you can have a tumor of one, two, three, sometimes four, but that's a much more unusual circumstance. When those tumors develop, they're not cancer, but they surely do a number on your health in a number of different ways and basically different end organs. A high calcium level can impact your kidney function, can give you kidney stones. It can cause osteoporosis, therefore it can affect the skeleton. It can cause problems with the cardiovascular system, hypertension, atrial fibrillation. But what most people complain of is what it does to the neurologic system, what it does to your brain function. It makes people tired and forgetful and achy and crabby and depressed, and they just don't feel like themselves. And those personality changes are what really bother people on a daily basis.

Joey Wahler (Host): So when we say parathyroid fake news as we did at the top, we're talking about misconceptions that patients sometimes have here, and I believe you addressed one of those already. One question that apparently patients do sometimes ask is "Can parathyroid glands be located 'anywhere'?"

Dr Douglas Politz: They can't really be just anywhere. It's a misconception that parathyroid glands can just sort of be anywhere in the whole body. They have to be between the chin and the heart. Now, that's a big range. These are normally tiny little things about the size and shape of a grain of rice. When they become a tumor, it's more like the size of maybe a grape or something along those lines, a kidney bean. But parathyroid glands are usually in very predictable places. And when you've done the procedure for this thousands and thousands of times, you start to learn in my view, it's like handicap parking places. They don't put those just anywhere. They don't put them a mile away from an entrance. They usually place those in very predictable spots. Next to an elevator, next to an on-ramp, next to the entrance. They don't put it a half a mile out in a parking lot away from everything. And parathyroid gland's locations are kind of like that. They are right next to a certain artery, right along the thyroid gland at the lower end of the thyroid gland or right along the side of the thyroid gland, right in a strip of fat called the thymus, things like that.

So it's probably helpful to get an appreciation here of the disease as it once was thought of, 1920s, the '20s and '30s. Those studies were of a few dozen patients, and we didn't know nearly as much as we know now about this disease. And so back then, you had to actually ask the lab to get a calcium level on a patient. So you had to actually suspect this disease to even know who to order a calcium level on. So it became people that had a kidney stone or had a broken bone, osteoporosis. And so those were the only people you tested. So it looked like everybody with this disease had kidney stones or had osteoporosis. But when we got to the 1940s and '50s, that's when the multiphasic screener came out, this chemistry machine where we all have had these blood tests. You'd get your blood drawn and out spits a sodium, potassium, chloride, calcium, magnesium, all these different blood tests, all these different chemicals in your blood. And we started to get these calcium levels that are high. And our colleagues are saying, "Do all of these people have parathyroid disease? Do all of these people need surgery?"

And then when we got to basically the 1990s, minimally invasive parathyroid operations came along where what were once big operations, big incisions on the neck, long procedures lasting hours and hours, a week long hospital stay, that became little small incisions in the neck, outpatient procedures, high cure rates, very low complication rates and therefore more and more patients were being diagnosed with it, more and more patients were being operated on. And therefore, our understanding of it was now based on so many more patients. And we have a great appreciation of what it's like to have the disease, how to diagnose it. And that's where I come up with the idea of fake news. We have all these misconceptions from back when we didn't have very many patients with it. Now, we have thousands of patients that we can draw upon the experience and the understanding of.

Joey Wahler (Host): Well, speaking again of those misconceptions, next question people sometimes ask is "The higher my calcium, the more likely I have more than one parathyroid tumor." Right or wrong?

Dr Douglas Politz: That's not true. It really doesn't have any effect. The higher your calcium, that doesn't really have an impact on how many of the parathyroid glands have a tumor. And it isn't a great indication of how severe the disease is. I often will say to patients, "It's the time, not the climb." It's how long your calcium is really above 10 as an adult. How long is your calcium elevated, not how high does it go? So if you have a calcium of 10.5 or 10.8 for 10 years, that does a lot more damage to your kidneys and your brain and your cardiovascular system, than if you have a calcium of 11.1 for a weekend. And so that's one of those misconceptions of, "Oh, well, the calcium is higher. I must have two tumors. I must have three tumors." It just doesn't work out that way.

Joey Wahler (Host): Okay. Now, that said, another question that some ask is, "Should I wait until I have osteoporosis or a kidney stone to have parathyroid surgery?"

Dr Douglas Politz: I get that question quite often in my practice. And it really is a function of where we are in the evolution of this. What I was saying earlier, if this were 1969, this were 1978, and the operation is this really big deal that has high complication rates, long admissions, six, seven hours of operating in your neck, "Okay, yeah, you know what? If we're talking about doing that kind of an operation, then it's probably good advice for you to just wait until this disease," that is not cancer by the way, -- these are benign tumors. They're not going to break off and spread somewhere else in your body -- "Wait until it actually does something that you can measure, something that actually does something significant to your health."

Now though, we have these operations. I mean, my partner, Dr. Lopez, and I would do this 10, 12 of these a day and we will make a little small incision and the procedure is an outpatient, it's over with in 20, 25 minutes and you go home an hour and a half, two hours later, if that's what you're talking about having done with virtually no chance of complication, it's way under 1%, and a upper 90s percent chance of success, well, heck, if that's the case, well, then I say, "No, you shouldn't wait for a kidney stone. You shouldn't wait for osteoporosis. Why would you do that when you can avoid that with something that is actually really well-tolerated?"

Joey Wahler (Host): Well, if it's that simple and easy a procedure, doc, no wonder you're doing 10 or 12 a day, right?

Dr Douglas Politz: Yes. If these were three hours each, well, the math isn't there for us to do 10 or 12 in a day.

Joey Wahler (Host): Couple of other misconceptions to address here. Another question often asked, "My parathyroid hormone level is normal. So does that mean I don't have a tumor?

Dr Douglas Politz: Every single day, I get that one. It's surprising how this is misconceived. The parathyroid hormone level is normal. Technically in the labs, normal range, about 16%, 17% of the time in people who have a parathyroid tumor. And the way to understand it is that it shouldn't be normal when your calcium is high. When a person has a high calcium level, that should shut off four normal parathyroid glands. They should really stop making parathyroid hormone and their parathyroid hormone level should be 6, 9, 12, 11, something on the low end. Most people live in the 20s and 30s in just a normal days' life, 20s and 30s. So if you have a patient who has a parathyroid hormone level, that is 35, 40, still in the normal range of the lab, but their calcium is high, well, that's too high. It should be really low and so something's making extra parathyroid hormone when it should be turned off, that's the definition of this disease. And that happens about 17% of the time.

Joey Wahler (Host): One other question that patients ask, "My scan is negative, so does that mean I don't need surgery?"

Dr Douglas Politz: Okay. That's an everyday one as well. I kid my radiology colleagues all the time with this. They have these fancy dancy scans for the brain and the joints and everything under the sun. We all know, we see these scans are so amazing in their quality, but not for parathyroid disease. I mean, for parathyroid disease, these nuclear scans, we get Sestamibi scans. A lot of times, they're very grainy and hazy and that's the technology. And so only about half of these tumors show up on Sestamibi scans, on our scans. Ultrasounds are not that great. I mean, ultrasounds will show some, but again, no more than about half of these. MRIs, CAT scans, just not really great imaging techniques to find these, yet people have parathyroid tumors. People have the disease. So if you have the disease, the answer is to have surgery because there is a famous radiologist who said in the 1980s, the best localizing test for a parathyroid tumor is to localize an experienced surgeon. In other words, we're going to look in the places that we look right behind the thyroid gland, and we're going to be able to find these things rather than wait for a scan to find it, which those things only show about half of these tumors.

Joey Wahler (Host): Now, was the famed doctor who came up with that quote, was that you doc or no?

Dr Douglas Politz: No, that was a guy named John Doppman, was his name. He was at the NIH. I was more of a young tyke back in the 1980s. I didn't even know what parathyroid glands were in the 1980s quite honestly.

Joey Wahler (Host): I thought maybe you're just being humble about not taking credit for the quote. Nah, I'm just kidding. Anyway, having debunked some of these misconceptions, what's the one takeaway you want people to have from our conversation?

Dr Douglas Politz: Parathyroid surgery is not what it used to be. Many of our colleagues were trained by doctors who were trained by doctors who had their practices and had their careers during the pre-minimally invasive parathyroid surgery era of this field and that was a much different time. This is a very well-tolerated procedure. Patients that have this disease, it's worth getting it fixed. There's a lot of diseases that pack the waiting rooms, well, back when we had waiting rooms. But there are diseases that you don't have a cure for, and it's everything you hear about, diabetes, asthma, allergies, rheumatoid arthritis, heart disease. We don't really have a cure for those things. We have great treatments, but we don't cure them. This is something we can cure and we can cure it with a pretty well-tolerated outpatient procedure and a little small incision on the neck and people leave an hour and a half, two hours later. I say, cure a curable disease.

Joey Wahler (Host): Well, we hope we've cleared up some parathyroid fake news here with our guest, Dr. Doug Politz. Hey, thanks so much again.

Dr Douglas Politz: It was great doing this with you. Thanks so much for doing this.

Joey Wahler (Host): Same here. Thanks for listening to MD cast by Tampa general hospital. Available on all major streaming services for free to collect your CME.

Please click on the link in the description for other CME opportunities, including live webinars on demand, videos and local events offered to you by Tampa general hospital, please visit CME dot T G h.org. Hoping your health is good health. I'm Joey Wahler.