What is the most appropriate next step in management for a patient with symptomatic primary hyperparathyroidism (fatigue, recurrent ureteric stones, bone pain, serum calcium 3.5 mmol/L) and a 2‑cm parathyroid adenoma?

Management of Symptomatic Primary Hyperparathyroidism with Parathyroid Adenoma

The most appropriate management is parathyroidectomy (Option D), which is the only definitive curative therapy for this patient with symptomatic primary hyperparathyroidism manifesting as recurrent nephrolithiasis, bone pain, and hypercalcemia (3.5 mmol/L) due to a 2 cm parathyroid adenoma. 1, 2

Rationale for Surgical Intervention

Parathyroidectomy is indicated for patients with clear target organ involvement, such as recurrent ureteric stones (nephrolithiasis) and bone pain indicating bone demineralization, particularly when a parathyroid adenoma has been identified. 1 The presence of symptomatic hypercalcemia with a 2 cm parathyroid adenoma makes this a straightforward surgical case, as surgery is typically indicated even when asymptomatic, given the potential negative effects of long-term hypercalcemia. 1, 3

Key Clinical Features Supporting Surgery:

• Recurrent nephrolithiasis represents definitive target organ damage requiring surgical correction 1, 2
• Bone pain indicates ongoing skeletal demineralization from excessive PTH 3
• Calcium 3.5 mmol/L represents significant hypercalcemia (normal ~2.2-2.6 mmol/L) 4
• 2 cm parathyroid adenoma is well above the typical size and readily amenable to surgical removal 1

Why Other Options Are Inappropriate

Option A: Bisphosphonates

Bisphosphonates are not indicated as primary management for symptomatic primary hyperparathyroidism with an identified adenoma. They do not address the underlying cause (autonomous PTH secretion) and would delay definitive treatment while the patient continues to experience target organ damage. 2

Option B: Calcimimetics

Calcimimetics may be considered only for severe hyperparathyroidism despite normocalcemia or hypercalcemic hyperparathyroidism unresponsive to other treatments, but they are not first-line therapy when a surgical cure is readily available. 2 Delaying surgery for medical management in symptomatic patients with clear target organ damage is not recommended. 1

Option C: Increased Calcium Diet

Increased calcium diet is completely contraindicated in hypercalcemia, as it would worsen the patient's already elevated calcium levels. 2 This option could precipitate a hypercalcemic crisis.

Surgical Approach

Minimally invasive parathyroidectomy (MIP) with intraoperative PTH monitoring is the appropriate approach for patients with a single adenoma, as it allows for confirmation of adequate removal of hyperfunctioning tissue. 1, 2 This approach offers:

• Shorter operating times 2
• Faster recovery 2
• Decreased costs compared to bilateral neck exploration 2

Preoperative imaging with ultrasound and/or dual-phase 99mTc-sestamibi scintigraphy with SPECT/CT should be performed to facilitate accurate localization prior to minimally invasive parathyroidectomy. 2, 5

Critical Post-Operative Management

Immediate Monitoring (First 48-72 Hours):

• Monitor ionized calcium every 4-6 hours to detect early hypocalcemia 1, 2
• If ionized calcium drops below 0.9 mmol/L, initiate calcium gluconate infusion at 1-2 mg elemental calcium/kg/hour 1

Transition to Oral Therapy:

• Once oral intake is tolerated, switch to calcium carbonate 1-2 g three times daily plus calcitriol up to 2 μg/day 1, 2
• This prevents "hungry bone syndrome" where previously suppressed bone rapidly remineralizes after parathyroidectomy, causing calcium to shift from serum into bone 2

Common Pitfalls to Avoid

• Do not delay surgical intervention in patients with recurrent renal stones and hyperparathyroidism, as this leads to progressive renal damage 2
• Do not rely solely on imaging results to decide on surgery; patients with high serum calcium and PTH should proceed to surgery independent of radiological findings 5
• Do not underestimate post-operative hypocalcemia risk; aggressive monitoring and early intervention prevent symptomatic complications 1, 2

Expected Outcomes

All patients with parathyroid adenoma are typically cured after operation, as determined by normalization of serum calcium levels in the postoperative period. 5 However, stone recurrence occurs in approximately 35% of patients within 2 years despite successful parathyroidectomy, highlighting the need for ongoing monitoring. 2