Parathyroidectomy is the Most Appropriate Next Step
This patient with symptomatic primary hyperparathyroidism (PHPT) due to a 2 cm parathyroid adenoma presenting with recurrent nephrolithiasis, bone pain, and hypercalcemia requires surgical excision of the abnormally functioning parathyroid tissue. 1
Rationale for Surgical Management
Parathyroidectomy is indicated for all symptomatic patients with PHPT and remains the only definitive curative therapy. 2
This patient has clear target organ involvement that mandates surgical intervention:
- Recurrent ureteric stones (nephrolithiasis) - a classic indication for surgery 1
- Bone pain indicating bone demineralization - another target organ manifestation 1
- Symptomatic hypercalcemia with fatigue - representing systemic effects 2
The presence of a 2 cm parathyroid adenoma with these symptoms makes this a straightforward surgical case, as surgery is typically indicated even when asymptomatic, given potential negative effects of long-term hypercalcemia. 1, 3
Why Medical Therapies Are Inappropriate
Medical therapies (bisphosphonates, calcimimetics) are only considered for patients who refuse surgery, are medically unfit, or have residual/recurrent disease inaccessible to further surgery. 4
- Bisphosphonates may address bone density but do not treat the underlying parathyroid pathology or prevent stone recurrence 5
- Calcimimetics are not definitive therapy and only manage hypercalcemia temporarily 5
- Increasing calcium intake would be contraindicated in a hypercalcemic patient 5
Parathyroidectomy is more cost-effective than observation or pharmacologic therapy in patients meeting surgical criteria. 2
Surgical Approach
For this patient with a single 2 cm adenoma:
- Preoperative imaging (cervical ultrasonography or sestamibi scan) should be performed for operative planning to facilitate minimally invasive parathyroidectomy (MIP) 3, 2
- MIP with intraoperative PTH monitoring is appropriate when imaging confidently localizes a single adenoma 1, 2
- Intraoperative PTH monitoring via a reliable protocol confirms adequate removal of hyperfunctioning tissue 2
Expected Outcomes
- Cure is defined as eucalcemia at more than 6 months postoperatively 2
- High-volume surgeons achieve better outcomes with cure rates exceeding 95% for single adenomas 2
- The patient's symptoms (bone pain, recurrent stones, fatigue) should resolve following successful parathyroidectomy 6, 7
Common Pitfalls to Avoid
- Do not perform preoperative parathyroid biopsy - this should be avoided 2
- Do not delay surgery for medical management in symptomatic patients with clear target organ damage 1, 2
- Ensure vitamin D levels are measured and deficiency corrected preoperatively 2
- Postoperative monitoring for hypocalcemia is essential, with calcium supplementation as needed 2
Answer: D. Parathyroidectomy