What is the most appropriate management for an elderly patient with incidentally discovered hypercalcemia, osteopenia, and elevated parathyroid hormone levels?

Management of Primary Hyperparathyroidism with Osteopenia

Order a parathyroid sestamibi scan to localize the adenoma in preparation for parathyroidectomy, as this patient meets clear surgical criteria for primary hyperparathyroidism (PHPT). 1

Clinical Presentation Analysis

This patient presents with biochemically confirmed PHPT:

• Elevated calcium (10.8 mg/dL) with elevated PTH (77 pg/mL) 2
• Elevated 24-hour urine calcium (260 mg/24h) excludes familial hypocalciuric hypercalcemia 2
• Adequate vitamin D levels (30 ng/mL) rule out secondary hyperparathyroidism 1, 3

The clinical findings demonstrate target organ damage:

• Significant height loss of 5 cm with thoracic kyphosis indicates vertebral compression fractures 1
• Osteopenia at multiple sites (T-scores -1.7 to -1.9) represents skeletal involvement 4

Why Surgery is Indicated

Parathyroidectomy is the only definitive cure for PHPT and is clearly indicated in this patient. 1 The presence of vertebral compression fractures (evidenced by height loss and kyphosis) constitutes symptomatic disease requiring surgical intervention, regardless of BMD measurements. 1, 4

Even without overt fractures, current guidelines recommend surgery for patients with:

• Age less than 50 years (this patient's exact age determines urgency)
• Osteoporosis (T-score ≤ -2.5) or fragility fractures
• Significant hypercalcemia
• Impaired renal function or nephrolithiasis 4

The vertebral compression fractures alone make this symptomatic PHPT requiring definitive surgical management. 1

Preoperative Localization

Imaging with sestamibi scan (option A) is the appropriate next step before surgery. 1 Preoperative localization with ultrasound and/or dual-phase 99mTc-sestamibi scintigraphy with SPECT/CT is highly sensitive for identifying parathyroid adenomas and facilitates minimally invasive parathyroidectomy. 1

Why Other Options Are Incorrect

Option B (thoracic/lumbar spine radiography): While this might document existing fractures, it does not change management since the height loss and kyphosis already indicate vertebral compression. The priority is treating the underlying cause (PHPT) rather than further documenting skeletal damage. 1

Option C (repeat labs in 6 months): Observation is inappropriate for symptomatic PHPT. Watchful waiting is only considered for truly asymptomatic patients without target organ damage who decline surgery or have contraindications. 4 This patient has clear skeletal complications requiring intervention.

Option D (start alendronate): Bisphosphonates may be used for skeletal protection in patients who cannot undergo surgery or refuse parathyroidectomy. 4 However, medical management does not address the underlying disease and should not delay definitive surgical treatment in appropriate surgical candidates. 1, 4 Alendronate treats the consequence (bone loss) but not the cause (autonomous PTH secretion).

Common Pitfalls to Avoid

• Do not delay surgical intervention in patients with evidence of target organ damage (fractures, nephrolithiasis, or significant osteoporosis), as progressive skeletal and renal complications will continue. 1, 5
• Do not mistake osteopenia for mild disease when clinical features (height loss, kyphosis) indicate vertebral fractures, which represent symptomatic PHPT. 1
• Do not initiate bisphosphonate therapy as primary treatment when surgery is indicated and feasible, as this only temporizes skeletal manifestations without curing the disease. 4