In a patient with fatigue, recurrent calcium‑containing ureteric stones, bone pain, serum calcium 3.5 mmol/L, and a 2 cm parathyroid adenoma, what is the most appropriate next step in management?

Parathyroidectomy is the Most Appropriate Next Step

This patient with symptomatic primary hyperparathyroidism (recurrent kidney stones, bone pain, hypercalcemia 3.5 mmol/L) and a 2 cm parathyroid adenoma requires immediate surgical parathyroidectomy—this is the only definitive curative treatment. 1, 2

Why Surgery is Indicated Now

Target organ damage is already present:

• Recurrent ureteric stones represent established renal complications from chronic hypercalcemia 1, 2
• Bone pain indicates ongoing skeletal demineralization from PTH excess 1, 2
• Serum calcium of 3.5 mmol/L (normal ~2.15-2.5 mmol/L) confirms significant hypercalcemia 3
• A 2 cm parathyroid adenoma is the clear source of autonomous PTH secretion 4, 5

Delaying surgery for medical management is not recommended when symptomatic patients have clear target-organ damage. 1, 2

Why the Other Options Are Inappropriate

Option A: Bisphosphonates

• Bisphosphonates are only temporizing agents for acute hypercalcemia management 2, 6
• They do not address the underlying autonomous PTH hypersecretion 2
• They provide no definitive treatment for primary hyperparathyroidism 2

Option B: Calcimimetics

• Calcimimetics may inhibit PTH secretion but are not curative 6
• They are reserved for patients who cannot undergo surgery or have failed surgery 6
• This patient has no contraindications to surgery and should proceed directly to definitive treatment 1, 2

Option C: Increased Calcium Diet

• This is completely contraindicated in hypercalcemia 1, 2
• Increasing dietary calcium would dangerously worsen the already elevated serum calcium of 3.5 mmol/L 1, 2
• Dietary calcium restriction has minimal effect on hypercalcemia driven by autonomous PTH secretion 2

Surgical Approach

Minimally invasive parathyroidectomy (MIP) is appropriate for this single adenoma: 1, 2, 5

• Pre-operative localization with 99mTc-sestamibi scan and/or neck ultrasound should be performed 1, 2, 5
• Intraoperative PTH monitoring confirms adequate removal of hyperfunctioning tissue 1, 2, 5
• MIP offers shorter operative times and faster recovery compared to bilateral neck exploration 2, 5

Parathyroidectomy by an experienced surgeon achieves 95-98% cure rates with low complication rates. 6, 5

Critical Post-operative Management

Hungry bone syndrome is a major risk after parathyroidectomy:

• Monitor ionized calcium every 4-6 hours for the first 48-72 hours 7, 1, 2
• If ionized calcium falls below 0.9 mmol/L, initiate calcium gluconate infusion at 1-2 mg elemental calcium/kg/hour 7, 1, 2
• Transition to oral calcium carbonate 1-2 g three times daily plus calcitriol up to 2 μg/day when oral intake is possible 7, 1, 2
• Discontinue or reduce phosphate binders based on serum phosphorus levels 7, 2

Common Pitfall to Avoid

Do not attempt medical management first in symptomatic patients with documented adenoma and target-organ damage. Surgery is curative and should be performed promptly. 1, 2, 3 Medical therapies (bisphosphonates, calcimimetics) are reserved for patients with surgical contraindications or those who refuse surgery—neither applies to this case. 2, 6

Answer: D. Parathyroidectomy