Cancer of the parathyroid glands

Cancer of the parathyroid glands is rare.

The parathyroid glands are part of the endocrine system. This system makes hormones that help to control the way your body works. They are attached to the thyroid gland at the front of the neck.

The parathyroid glands make parathyroid hormone (PTH). This helps control calcium levels in the blood. Parathyroid cancer usually causes high levels of calcium in the blood (hypercalcaemia). Symptoms include:

  • feeling thirsty and passing a lot of urine
  • tiredness
  • feeling or being sick
  • mood changes
  • tummy or back pain
  • indigestion
  • loss of appetite
  • constipation
  • muscle weakness.

You may have blood and urine tests, and scans to check your parathyroid glands.

The main treatment is surgery.

Surgery can also be used if a cancer comes back again or spreads. Radiotherapy and radiofrequency ablation are sometimes used. You may also have other treatments, such as drugs to control the level of calcium in your blood.

You will have regular check-ups and blood tests after treatment is over. These will probably continue for several years.

The parathyroid glands

There are four small parathyroid glands. They are attached to the thyroid gland in the front of the neck. The thyroid gland and the parathyroid glands are close to each other and have similar names, but they are different and do different things.

We have information about thyroid cancer, which is a different type of cancer and is treated differently.

Position of the parathyroid glands
Position of the parathyroid glands

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The parathyroid glands are part of the endocrine system. This system makes hormones that help to control the way your body works.

The parathyroid glands make parathyroid hormone (PTH). This helps control calcium levels in the blood. Calcium helps your muscles and nerves work, builds strong bones and helps your blood to clot.

Most of the calcium in the body is stored in the bones. PTH makes the bones release calcium into the blood. When calcium levels in the blood are high, the parathyroid glands produce less PTH and calcium levels drop.


Causes and risk factors for parathyroid cancer

We don’t know what causes parathyroid cancer in most people. But people who have genetic conditions such as multiple endocrine neoplasia 1 (MEN1) or familial hyperparathyroidism have a higher risk of parathyroid cancer. These are rare conditions caused by a gene change (mutation) passed on from parent to child (inherited).

People who have had radiotherapy treatment to their neck area have an increased risk of developing non-cancerous (benign) parathyroid tumours. They may also have an increased risk of developing cancer of the parathyroid gland.


Signs and symptoms of parathyroid cancer

Most people with parathyroid cancer (about 9 in 10) make too much PTH. This causes high levels of calcium in the blood (hypercalcaemia).

Common symptoms of hypercalcaemia include:

  • feeling thirsty and passing a lot of urine
  • tiredness
  • feeling sick or being sick (vomiting)
  • changes in mood – feeling low, depressed, irritable or nervous
  • pain in the tummy or back
  • indigestion
  • loss of appetite
  • constipation
  • muscle weakness.

Untreated hypercalcaemia can cause bone thinning, due to the bones losing calcium. This can lead to bone damage, including broken bones (fractures) and pain.

High calcium levels in the blood can affect the kidneys. Some people develop kidney stones, or their kidneys may become damaged and not work as well.

Rarely, people with parathyroid cancer have a lump or swelling in their neck. This can sometimes cause difficulty swallowing and a hoarse voice.


Diagnosing parathyroid cancer

You usually start by seeing your GP, who will examine you and ask about your symptoms and general health. Your GP may arrange tests. If they are unsure what the problem is, or think that your symptoms could be caused by cancer, they will refer you to a hospital for specialist advice and treatment.

Sometimes it can be difficult to diagnose parathyroid cancer before an operation to remove the tumours in the parathyroid glands. This is because the symptoms can be similar to those caused by non-cancerous tumours.

Parathyroid cancer is sometimes diagnosed following a routine blood test, and you may have no symptoms at all. If the blood test shows a high calcium level, it may suggest a parathyroid tumour.

Tests for parathyroid cancer may include the following.

Blood and urine tests

Samples of blood and urine will be taken to check your calcium and PTH levels. For the urine test, your doctor may ask you to collect all the urine you pass in 24 hours. For some blood tests, the doctor will ask you to not eat (to fast) overnight before they take the sample. You should follow any instructions carefully to get clear results.

Ultrasound scan

An ultrasound scan uses sound-waves to build up a picture of the parathyroid glands and other structures inside the neck.

You will be asked to lie on your back for the scan. Once you are lying comfortably, the person doing the scan spreads a gel over your neck. Then they move a small hand-held device like a microphone around your neck area. A picture of the inside of your neck shows up on a screen. An ultrasound only takes a few minutes and is painless.

Parathyroid scan (sestaMIBI scan)

This scan shows the size and position of the parathyroid glands, and any abnormal areas. To have this scan, you visit the hospital scanning department twice on the same day. 

Before the scan, you have an injection of a radioactive substance (called sestaMIBI). The radiation dose is low and very unlikely to harm you. But always tell your doctor or staff in the scanning department before the scan if:

  • you are, or think you could be, pregnant
  • you are breastfeeding.

The person doing the scan injects the radioactive substance into a vein in your arm. Then you wait for about 10 minutes for your parathyroid glands to absorb the substance. After this, a camera that can detect radioactivity (a gamma camera) moves around your head and takes pictures of your neck. You need to lie still for about 40 minutes while this happens. Tell your doctor or the staff doing the scan if:

  • you think you might not be able to lie still
  • you find it difficult to be in closed-in spaces (claustrophobia).

After the first part of the scan, you can leave the scanning department. Then you go back after three hours to have more pictures taken of your neck. This may take 30 to 40 minutes.

If you are taking thyroid medications, you may need to stop taking them before you have the scan. Your doctor will advise you about this.

You should avoid close contact with pregnant women and very young children for 24 hours after this test. This is because your body will release a small amount of radioactivity. The staff doing the test can tell you more about this.


Further tests

You may have further tests to see if there are signs the cancer has spread outside the parathyroid glands.

CT (computerised tomography) scan

A CT scan takes a series of x-rays. These build up a three-dimensional picture of the inside of the body.

MRI (magnetic resonance imaging) scan

MRI uses magnetism instead of x-rays to build up a detailed picture of areas of your body.

PET (positron emission tomography) scan

A PET scan uses low-dose radioactive glucose (a type of sugar) to measure the activity of cells in different parts of the body.


Staging

Staging describes if the cancer has spread from where it first started to other parts of the body.

Parathyroid cancer is staged as localised or metastatic:

  • Localised parathyroid cancer is in a parathyroid gland and may have spread to nearby tissues such as the thyroid, gullet (oesophagus), the nerve for the voicebox (laryngeal nerve), or nearby muscle.
  • Metastatic parathyroid cancer is also called secondary or advanced cancer. It means it has spread to other parts of the body, such as the lymph nodes, lungs, liver or bones.


Treatment

The treatment you have will depend on the stage of the cancer and your general health.

The main treatment for parathyroid cancer is surgery. It is often the only treatment needed. Surgery can also be used to treat cancer that comes back again, or if the cancer spreads to other areas of the body.

Sometimes, radiotherapy is used to reduce the risk of cancer coming back after surgery.

Chemotherapy may be given if you can’t have surgery.

You may also need other treatments to control the level of calcium in your blood.


Surgery

A surgeon will remove the parathyroid gland containing the cancer and any nearby affected areas. They may also remove half of the thyroid gland on the same side as the cancer, and some nearby lymph nodes in the neck.

Surgery may also be used to remove cancer that has come back in the neck area. Your specialist can give you more information.

Before your operation

You may visit a pre-assessment clinic before your operation. You will have some tests to check your general health. These may include:

  • blood tests
  • a chest x-ray
  • a recording of your heart (ECG).

You will see a member of the surgical team and, in some hospitals, a specialist nurse. They will talk to you about your operation. This is a good opportunity to ask questions and talk about any concerns you have. You will see the doctor who gives you your anaesthetic (the anaesthetist) either at a clinic or when you are admitted to hospital.

Before and after surgery, a doctor will check your vocal cords. This is because the nerves that control your vocal cords are close to the parathyroid glands. The doctor may use a local anaesthetic spray to numb your nose and throat. Then they will pass a thin, flexible tube with a small camera at the end (nasendoscope) through your nose to look at how your vocal cords move. This can be a little uncomfortable, but it should not be painful.

You may be asked to avoid eating or drinking for a few hours after the test, until the local anaesthetic wears off.

You will see the doctor who gives you your anaesthetic (the anaesthetist) either at a clinic or when you are admitted to hospital.

You will usually be admitted to hospital the day before or on the morning of your operation. The nurses may give you elastic stockings (TED stockings) to wear during and after the operation. These help prevent blood clots forming in your legs.

After your operation

The nurses on the ward will help you to lie in a fairly upright position, supported by pillows. This helps to reduce swelling in your neck area.

You will probably have some pain or discomfort. Your doctor will prescribe painkillers for you. Talk to your doctor or nurse about any pain you have. Your neck will feel stiff after surgery. Your nurse, surgeon or physiotherapist will show you some neck exercises to help with this.

You may have a drip (intravenous infusion) going into your arm to replace your body’s fluids. You should be able to start drinking an hour or so after your operation. You may find it painful to swallow at first. This should improve over the next two or three days.

You may also have one or two tubes (drains) to drain fluid from your wound. These are usually removed within 24 to 48 hours.

After surgery to remove a parathyroid gland, the level of calcium in your blood may become low. It can take two or three days for the calcium level to go back to normal after surgery.

You will have regular blood tests to check your calcium levels. If the level is too low, your doctor will prescribe extra calcium. You usually have the calcium as tablets, or sometimes you have it by injection into a vein (intravenously). Your doctor may also prescribe vitamin D supplements, to help your body absorb calcium from the food you eat.

You will probably have some small scars on your neck after the operation. These usually fade as they heal.

Rarely, surgery can damage a nerve in the neck. This can cause hoarseness or problems with how you swallow. If this happens, your doctor or specialist nurse will talk to you about how long these effects may last. Very rarely, you may need support from a speech and language therapist who can help with swallowing problems.


Radiotherapy

Radiotherapy is not often given for parathyroid cancer. It is sometimes used:

  • after surgery to reduce the risk of the cancer coming back
  • if the cancer comes back (recurs).

This treatment uses high-energy rays to treat cancer. It works by destroying cancer cells in the area being treated.

Planning your treatment

Before you start your treatment, it needs to be carefully planned. Planning makes sure that the radiotherapy is aimed precisely at where the cancer was removed, so that it causes the least possible damage to the surrounding healthy tissue.

You will need to have a mould or mask made before your treatment is planned. This is to keep your head still while you have your treatment.

Having radiotherapy

You normally have radiotherapy as a series of short, daily outpatient treatments with a rest at the weekend. You have it in the radiotherapy department, using equipment similar to a large x-ray machine. How many treatments you have will depend on the aim of your treatment. Your doctor or specialist nurse will be able to tell you how many treatments you are likely to have.

Side effects

You may develop side effects during radiotherapy. These usually disappear gradually over a few weeks or months after treatment finishes. Your radiotherapy team will let you know what to expect. Tell them about any side effects you have. There are often things that can be done to help.

Radiotherapy can cause general side effects such as tiredness (fatigue).

Specific side effects of radiotherapy to the neck can include:

Your doctor, specialist nurse or radiotherapist will discuss any possible side effects with you before you start your treatment.


Chemotherapy

This treatment uses anti-cancer (cytotoxic) drugs to destroy cancer cells.

Chemotherapy is rarely used to treat parathyroid cancer, but may be used if surgery isn’t possible. Your doctor or specialist nurse will give you more information.


Radiofrequency ablation

Radiofrequency ablation is sometimes used to treat parathyroid cancer that has spread to another part of the body (secondary or advanced cancer). It uses heat to destroy cancer cells, and helps to reduce the level of parathyroid hormone being made in the body.

Your doctor will give you a local anaesthetic and sedation before the treatment begins. In some cases, you will have a general anaesthetic instead. Your doctor will place a needle into the tumour. This is usually done using a CT scanner to make sure the needle is in the right place. The doctor then passes radio-waves down the needle into the tumour to heat and destroy the cancer cells.

There are not many side effects with this treatment, but you may have some discomfort or feel tired afterwards. You will usually need to stay in hospital overnight.


Clinical trials

Research trials are done to try to find new and better treatments for cancer. Because parathyroid cancer is rare, it is difficult to research new treatments. Ask your doctor or specialist nurse if there are any clinical trials suitable for you.

ClinicalTrials.gov is a website that has up-to-date international clinical trials, including UK trials.


Treatments for hypercalcaemia

If the levels of calcium in your blood are high (hypercalcaemia), you will need treatment to control this. Some people stay in hospital for a short while to have a drip (infusion) into a vein to prevent dehydration and drugs to lower the calcium levels. You may need to take medicines for a longer time to keep your calcium levels stable.

You may have treatment to lower your calcium levels:

  • before surgery to remove a parathyroid cancer completely
  • if the cancer has spread
  • if the cancer cannot be removed with surgery.

You may have the following drugs.

Bisphosphonates

Most of the calcium in the body is stored in the bones. Bisphosphonates are drugs that stop the bones releasing calcium into the blood.

Some types of bisphosphonate are given as a drip into a vein. You can have this treatment as an outpatient. It takes 15 to 60 minutes and you usually have it every 3 to 4 weeks.

You can also take bisphosphonates as tablets or capsules. If you are prescribed these, your doctor, specialist nurse or pharmacist will explain how you should take them.

Denosumab

Denosumab is a type of cancer drug called a monoclonal antibody. Monoclonal antibodies are also called targeted therapies, because they work by ‘targeting’ specific proteins that are either produced by cells or found on the surface of cells (receptors).

Denosumab is used to lower calcium levels and to prevent bones breaking (fractures) in people with advanced cancer.

Denosumab is given as an injection, just under the skin (subcutaneous injection).

Drugs that reduce parathyroid hormone production

These drugs work by reducing the amount of parathyroid hormone (PTH) made in the body. PTH makes the bones release calcium into the blood. The most common drug of this type is a tablet called cinacalcet (Mimpara®). Your doctor, specialist nurse or pharmacist will give you more information. They will tell you how often you should take the tablets and how often you should get your calcium and PTH levels checked.

Calcitonin

You have this drug as an injection under the skin (subcutaneously) or into a muscle. You usually have it every 6 to 8 hours.

If the level of calcium in your blood is very high, you may have calcitonin as a drip (infusion). It is given over six hours during a short stay in hospital.


Follow-up

You will have regular check-ups and blood tests after your treatment has finished. These will probably continue for several years. Because parathyroid cancer is rare, you will usually be followed up by a specialist endocrinology team.

If you have any problems or notice any symptoms between check-ups, let your doctor or specialist nurse know as soon as possible.


Your feelings

It is common to feel overwhelmed by different feelings when you are told you have cancer. These can include anger, fear and resentment. Some people find it helpful to talk to family or friends, while others prefer to seek help from people outside their situation. Some people prefer to keep their feelings to themselves. There is no right or wrong way to manage your feelings.

Having these feelings can be difficult and sometimes people need more help to cope with them. This happens to lots of people and doesn’t mean you are not coping. If you feel anxious, panicky or sad a lot of the time, or think you may be depressed, talk to your doctor or nurse. They can refer you to a doctor or a counsellor who can help. They may also be able to prescribe medicine to help with anxiety or depression.

Our cancer support specialists can give you information about support in your area. We have a thyroid cancer information nurse who you can arrange to speak with.

Our information about the emotional effects of cancer talks about the feelings you may have in more detail, and has suggestions for coping with them.


Other useful organisations

The following organisations can also give you information and support:

  • AMEND: The Association for Multiple Endocrine Disorders. A patient group that offers information, support and counselling to people affected by MEN disorders. Its online community is also a good place to meet people who may be in a similar situation.
  • Butterfly Thyroid Cancer Trust. Offers information, support and encouragement for people with thyroid cancer. You can talk to other people with thyroid cancer through the helpline (by email and phone), or by arranging for a buddy to help you through treatment.