A 50-year-old man presents with hypercalcemia (serum calcium 11.8 mg/dL), normal renal function, and a serum PTH of 85 pg/mL (normal: 15-65 pg/mL). A Sestamibi scan localizes to the lower right parathyroid. What is the most appropriate surgical approach?

• A Four-gland exploration with bilateral neck dissection
• B Preoperative cinacalcet therapy to normalize calcium before surgery
• C Minimally invasive parathyroidectomy (focused exploration) with intraoperative PTH monitoring ✓
• D Bilateral exploration regardless of imaging localization

Explanation

Minimally invasive parathyroidectomy (MIP) with intraoperative PTH monitoring (using the Miami criterion: >50% drop in PTH within 10 minutes of adenoma excision) is the standard approach for primary hyperparathyroidism with a single-gland localized adenoma on Sestamibi scan. A >50% fall in PTH to within the normal range predicts cure. This approach has equivalent cure rates (>95%) to bilateral four-gland exploration but with reduced operative time, complications, and hospital stay. Cinacalcet is a medical adjunct, not a preoperative treatment.

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

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Written and medically reviewed by the StethoPrep medical team.