A 65-year-old woman has persistently elevated serum calcium (3.1 mmol/L) and PTH 120 pg/mL (elevated). Sestamibi SPECT scan is negative. 4D-CT localization also fails to identify a single adenoma. What is the most appropriate surgical strategy?

• A Minimally invasive parathyroidectomy guided by intraoperative PTH alone
• B Cinacalcet (calcimimetic) medical management indefinitely
• C Bilateral neck exploration with four-gland assessment ✓
• D Repeat sestamibi after 6 months — imaging will become positive

Explanation

When preoperative localization studies fail to identify a single adenoma in primary hyperparathyroidism, bilateral neck exploration with four-gland identification is the recommended approach. Failed localization may indicate multiglandular disease (double adenoma or 4-gland hyperplasia), which occurs in 15–20% of cases and cannot be managed by focused unilateral exploration. Intraoperative PTH monitoring guides adequacy of resection during bilateral exploration. Cinacalcet is reserved for inoperable patients or surgical failures. Minimally invasive parathyroidectomy is inappropriate without successful localization.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.