A 48-year-old woman has primary hyperparathyroidism with calcium of 15.6 mg/dL, intact PTH eight times the upper limit, a firm palpable neck mass, and a paralysed right vocal cord. Frozen section of the excised gland shows marked pleomorphism, mitoses, and capsular invasion by trabeculae of chief cells. The most appropriate operative strategy is:

• A Simple excision of the enlarged gland only
• B En bloc resection of the tumour with ipsilateral thyroid lobectomy and any invaded soft tissue ✓
• C Subtotal parathyroidectomy with autotransplantation
• D Excision followed by adjuvant radiotherapy to the neck

Explanation

Marked hypercalcaemia above 14 mg/dL, PTH three to ten times normal, a palpable mass, and vocal cord palsy are classic for parathyroid carcinoma. Cure depends on complete en bloc resection at the first operation, removing the tumour with the ipsilateral thyroid lobe and invaded structures while avoiding capsular breach, since spillage seeds local recurrence. Simple excision leaves positive margins, and radiotherapy has little established role. Recurrence rates exceed 50 percent if the capsule is breached.

Reference: Sabiston Textbook of Surgery, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.