A patient with fatigue, recurrent ureteric stones, bone pain, marked hypercalcemia, and a 2‑cm parathyroid adenoma, without polyuria, polydipsia, or CNS symptoms, what is the most appropriate next step in management?

Parathyroidectomy is the Most Appropriate Next Step

For this patient with symptomatic primary hyperparathyroidism—presenting with recurrent ureteric stones, bone pain, marked hypercalcemia (3.50 mmol/L), and a 2 cm parathyroid adenoma—parathyroidectomy is the definitive and only curative treatment that should be performed promptly. 1

Why Surgery is Indicated

This patient has clear target organ involvement that makes surgery unequivocally indicated:

• Recurrent nephrolithiasis (ureteric stones) is a major surgical indication for parathyroidectomy 1, 2
• Bone pain indicates bone demineralization and ongoing skeletal complications 1
• Marked hypercalcemia at 3.50 mmol/L (normal ~2.15-2.50 mmol/L) represents significant elevation requiring definitive treatment 3
• Symptomatic disease with fatigue and end-organ damage makes this a straightforward surgical case 1, 2

The American Association of Endocrine Surgeons guidelines explicitly state that parathyroidectomy is indicated for all symptomatic patients 2. Delaying surgery for medical management in symptomatic patients with clear target organ damage is not recommended 1.

Why Medical Management is Inappropriate

Bisphosphonates (Option A) - Incorrect

• Bisphosphonates are only considered for patients who meet surgical criteria but cannot undergo surgery due to contraindications 4
• They do not address the underlying pathology (the adenoma) and provide only symptomatic control 5
• Post-surgical bisphosphonate continuation showed no advantage and cannot be recommended 6

Calcimimetics (Option B) - Incorrect

• Calcimimetics (like cinacalcet) are reserved for patients who meet surgical guidelines but are not surgical candidates 4
• They suppress PTH secretion but do not cure the disease 5
• This patient has no contraindications to surgery and should not receive medical temporizing measures

Increased Calcium Diet (Option C) - Contraindicated

• Increasing calcium intake is completely contraindicated in hypercalcemia, as it would worsen the patient's already elevated calcium levels 1
• This option could precipitate hypercalcemic crisis with cardiac and renal complications 3

Surgical Approach

Minimally invasive parathyroidectomy (MIP) with intraoperative PTH monitoring is the appropriate surgical technique for this patient with a single 2 cm adenoma 1, 7:

• Preoperative localization imaging (ultrasound and 99mTc-sestamibi scan with SPECT/CT) should be obtained to facilitate MIP 7, 2
• Intraoperative PTH monitoring confirms adequate removal of hyperfunctioning tissue (≥50% drop from baseline) 7, 2
• Both focused MIP and bilateral exploration achieve high cure rates (95-98%), but MIP offers shorter operative time and faster recovery when imaging is concordant 7, 2

Critical Perioperative Management

Preoperative Preparation

• Measure 25-hydroxyvitamin D levels and correct deficiency (<75 nmol/L), as this is a risk factor for severe postoperative hypocalcemia 7, 2
• Obtain baseline 24-hour urine calcium (likely >400 mg/day given recurrent stones) 2

Postoperative Monitoring

• Monitor ionized calcium every 4-6 hours for the first 48-72 hours post-operatively 8, 1
• If ionized calcium falls below 0.9 mmol/L (corrected total calcium <7.2 mg/dL), initiate calcium gluconate infusion at 1-2 mg elemental calcium/kg/hour 8, 1
• Transition to oral calcium carbonate 1-2 g three times daily plus calcitriol up to 2 μg/day when oral intake is possible 8, 1
• Phosphate binders may need to be discontinued or reduced based on serum phosphorus levels 8

Common Pitfalls to Avoid

• Do not delay surgery for medical optimization in symptomatic patients with clear complications—surgery is curative and should be performed promptly 1
• Do not attempt preoperative parathyroid biopsy—this should be avoided 2
• Do not assume imaging is needed to diagnose hyperparathyroidism—imaging is only for preoperative localization after biochemical diagnosis is established 9
• Do not underestimate the risk of hungry bone syndrome postoperatively in patients with significant bone disease—aggressive calcium and vitamin D supplementation will be needed 1, 6