Management of Symptomatic Primary Hyperparathyroidism with Parathyroid Adenoma
Parathyroidectomy is the definitive and most appropriate next step for this patient with symptomatic primary hyperparathyroidism (PHPT) due to a 2cm parathyroid adenoma, presenting with recurrent kidney stones, bone pain, and hypercalcemia. 1
Rationale for Surgical Intervention
This patient meets multiple established surgical criteria for parathyroidectomy:
- Symptomatic disease: The presence of recurrent ureteric stones, bone pain, and fatigue represents classic symptomatic PHPT requiring surgical correction 2, 3
- Kidney stone disease: Nephrolithiasis is a well-established indication for parathyroidectomy in PHPT 2, 4
- Hypercalcemia: Calcium level of 3.50 mmol/L (normal range approximately 2.15-2.55 mmol/L) represents significant hypercalcemia exceeding >0.25 mmol/L above the upper limit of normal, which is a surgical indication 2
- Adenoma size: A 2cm parathyroid adenoma is substantial and biochemically confirmed as the source of PHPT 1
Why Not Medical Management?
Bisphosphonates (Option A) are not appropriate as primary treatment because:
- They only address bone complications temporarily without treating the underlying parathyroid disease 3
- Surgery is the definitive treatment for PHPT with a localized adenoma 1, 4
- Medical management is reserved only for patients who cannot undergo surgery, refuse surgery, or do not meet surgical criteria—none of which apply here 3
Calcium restriction (Option B) is contraindicated because:
- Dietary calcium manipulation does not address the autonomous PTH secretion from the adenoma 3
- The hypercalcemia is PTH-mediated, not dietary in origin 2
Increasing calcium intake (Option C) would worsen hypercalcemia and is completely inappropriate 3
Preoperative Preparation
Before surgery, the following steps should be completed:
- Preoperative localization imaging: Parathyroid sestamibi scan (99mTc-sestamibi with SPECT/CT) and/or neck ultrasound to facilitate minimally invasive parathyroidectomy 1, 2
- Vitamin D assessment: Check 25-hydroxyvitamin D levels, as deficiency can complicate interpretation and postoperative management 2
- Renal function evaluation: Measure serum creatinine to assess kidney function given the history of recurrent stones 2
- 24-hour urine collection: Assess for hypercalciuria (>400 mg/day indicates increased stone risk) and other metabolic abnormalities 2
Expected Outcomes
- Immediate symptom resolution: Previously unrecognized symptoms often resolve after surgical correction, even in patients initially thought to be "asymptomatic" 4
- Biochemical normalization: Serum calcium typically normalizes immediately postoperatively 5, 6
- Stone prevention: Parathyroidectomy addresses the underlying cause of recurrent nephrolithiasis 2, 4
- Bone health improvement: Surgical correction prevents progressive bone complications 3, 6
Critical Postoperative Monitoring
- Hungry bone syndrome risk: Monitor for postoperative hypocalcemia, which may require temporary calcium and calcitriol supplementation 6
- PTH levels: Undetectable PTH immediately postoperatively is expected and confirms successful adenoma removal 6
Answer: D. Parathyroidectomy