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

Parathyroidectomy Is the Definitive Next Step

This patient requires immediate parathyroidectomy—it is the only curative therapy for symptomatic primary hyperparathyroidism with clear target-organ damage (recurrent kidney stones, bone pain, severe hypercalcemia). 1, 2

Why Surgery Is Indicated Now

This patient meets multiple absolute indications for parathyroidectomy:

• Symptomatic disease with target-organ involvement: Recurrent nephrolithiasis and bone pain represent clear complications of primary hyperparathyroidism that mandate surgical intervention 1, 2
• Severe hypercalcemia: Serum calcium of 3.5 mmol/L (approximately 14 mg/dL) is significantly elevated and poses risk for life-threatening complications including cardiac arrhythmias and acute kidney injury 3
• Identified parathyroid adenoma: The 2 cm parathyroid adenoma confirms the source of autonomous PTH overproduction and makes this a straightforward surgical case 1, 2
• Delaying surgery is not recommended: Medical management in symptomatic patients with clear target-organ damage is inappropriate 1, 2

Why the Other Options Are Incorrect

Bisphosphonates (Option A)

• Bisphosphonates serve only as temporizing agents for acute hypercalcemia and do not provide definitive treatment of primary hyperparathyroidism 2
• They may be used as a bridge to surgery in hypercalcemic crisis, but surgery remains the definitive treatment 2

Calcitonin (Option B)

• Calcitonin is similarly only a temporary measure for acute severe hypercalcemia 4
• It does not address the underlying autonomous parathyroid hormone secretion from the adenoma 2

Increased Calcium Diet (Option C)

• Completely contraindicated: Increasing dietary calcium would exacerbate the patient's already dangerously elevated serum calcium levels 1, 2
• This option could precipitate hypercalcemic crisis with cardiac and renal complications 3

Surgical Approach and Planning

Preoperative Localization

• Obtain 99mTc-sestamibi scintigraphy and/or neck ultrasound before surgery to facilitate minimally invasive parathyroidectomy 1, 2, 5
• The combination of both imaging modalities offers the highest sensitivity for adenoma localization 6

Surgical Technique

• Minimally invasive parathyroidectomy (MIP) with intraoperative PTH monitoring is the preferred approach for a single localized adenoma 1, 2, 5
• MIP provides shorter operative times, faster recovery, and lower costs compared to bilateral neck exploration 2
• Intraoperative PTH monitoring confirms complete excision of hyperfunctioning tissue 1, 2, 5

Critical Postoperative Management

Hungry Bone Syndrome Risk

This patient is at high risk for hungry bone syndrome given the severe, symptomatic disease with bone pain:

• Monitor ionized calcium every 4–6 hours for the first 48–72 hours postoperatively 1, 2
• If ionized calcium falls below 0.9 mmol/L: Initiate calcium gluconate infusion at 1–2 mg elemental calcium/kg/hour 1, 2
• Transition to oral therapy: Calcium carbonate 1–2 g three times daily plus calcitriol up to 2 µg/day once oral intake is tolerated 1, 2
• Adjust phosphate binders based on serum phosphorus to avoid exacerbating hypocalcemia 2

Common Pitfalls to Avoid

• Do not delay surgery for medical management in symptomatic patients—this patient needs definitive treatment now 1, 2
• Do not attempt preoperative parathyroid biopsy—it is unnecessary and potentially harmful 5
• Do not underestimate postoperative hypocalcemia risk—the severity of preoperative disease predicts aggressive hungry bone syndrome 1, 4
• Ensure surgeon experience—high-volume parathyroid surgeons have significantly better outcomes 5

The correct answer is D: Parathyroidectomy.