What is the most appropriate next step in management for a patient with primary hyperparathyroidism, presenting with fatigue, recurrent ureteric stones, bone pain, and a confirmed 2cm parathyroid adenoma, with hypercalcemia (calcium level: 3.50 mmol/L) and no symptoms of polyuria, polydipsia, or central nervous system (CNS) involvement?

Parathyroidectomy is the Most Appropriate Next Step

This patient with symptomatic primary hyperparathyroidism (recurrent ureteric stones, bone pain, fatigue) and a confirmed 2cm parathyroid adenoma with significant hypercalcemia (3.50 mmol/L) requires urgent surgical parathyroidectomy. 1

Rationale for Immediate Surgical Intervention

This patient meets multiple clear indications for parathyroidectomy:

• Target organ damage is present: Recurrent nephrolithiasis (ureteric stones) and bone pain indicating bone demineralization are established surgical indications 1
• Significant hypercalcemia: At 3.50 mmol/L (normal ~2.15-2.55 mmol/L), this represents severe hypercalcemia that warrants urgent intervention 2
• Confirmed adenoma: The 2cm parathyroid adenoma is the definitive source requiring removal 1
• Symptomatic presentation: Fatigue combined with end-organ complications makes this a straightforward surgical case 1, 3

Why Medical Management is Inappropriate

Delaying surgery for medical management in symptomatic patients with clear target organ damage is not recommended 1:

• Bisphosphonates (Option A) are temporizing measures only and do not address the underlying pathology 2
• Calcium restriction (Options B and C) will not resolve hyperparathyroidism from an autonomous adenoma 4
• Medical therapy with aggressive hydration, calcitonin, denosumab, or pamidronate may fail to control severe hypercalcemia from parathyroid adenomas 2

Surgical Approach

Minimally invasive parathyroidectomy with intraoperative PTH monitoring is the appropriate surgical technique 1:

• Single adenomas are amenable to focused parathyroidectomy rather than bilateral neck exploration 1
• Intraoperative PTH should drop significantly (>50% from baseline) after adenoma removal, confirming adequate resection 4
• In this case with a 2cm adenoma, preoperative localization imaging (sestamibi scan and/or ultrasound) should be obtained to facilitate the minimally invasive approach 1, 5

Critical Clinical Context

Parathyroid adenomas account for 80-85% of primary hyperparathyroidism cases, and surgery is the only definitive curative therapy 4, 3:

• The combination of symptomatic hypercalcemia with documented adenoma makes this a medical emergency requiring prompt surgical consultation 2
• Even asymptomatic patients with primary hyperparathyroidism often require surgery given the long-term negative effects of hypercalcemia, including persistent hypertension, progressive bone disease, and renal dysfunction 1
• Patients with severe hypercalcemia (>3.5 mmol/L) can develop hyperparathyroid crisis with neurological deterioration, requiring urgent parathyroidectomy 2

Common Pitfalls to Avoid

• Do not delay surgery for prolonged medical optimization in symptomatic patients with confirmed adenomas 1
• Do not mistake this for secondary hyperparathyroidism: This patient has primary hyperparathyroidism (adenoma-driven) with hypercalcemia, not secondary hyperparathyroidism from chronic kidney disease which presents with normal/low calcium 5
• Do not use imaging to diagnose: The biochemical diagnosis (hypercalcemia + elevated/inappropriately normal PTH) establishes primary hyperparathyroidism; imaging is only for preoperative localization 5

Answer: D. Parathyroidectomy