A 50-year-old man is diagnosed with sporadic primary hyperparathyroidism. Sestamibi scan localizes a single right inferior parathyroid adenoma. Intraoperative PTH monitoring shows a drop from baseline of 450 pg/mL to 85 pg/mL at 10 minutes post-excision (Miami criterion: >50% drop into normal range). However, the surgeon palpates a second enlarged gland on the contralateral side. What is the most appropriate surgical approach?

• A Close the neck and plan for medical management with cinacalcet
• B Perform focused parathyroidectomy only on the localized adenoma and ignore the contralateral finding
• C Remove both the localized adenoma and the contralateral enlarged gland without further exploration
• D Convert to bilateral neck exploration and evaluate all four glands ✓

Explanation

When a second enlarged gland is identified intraoperatively during focused parathyroidectomy, the procedure should be converted to bilateral neck exploration to evaluate all four glands. Multigland disease (double adenomas or four-gland hyperplasia) occurs in 15-20% of sporadic primary hyperparathyroidism. Intraoperative PTH may drop sufficiently after removing one adenoma even when a second abnormal gland exists, leading to persistent or recurrent disease if the second gland is left in situ. Exploring all glands ensures complete treatment.

Reference: Schwartz's Principles of Surgery, 11th ed.

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Written and medically reviewed by the StethoPrep medical team.