A 48-year-old man has primary hyperparathyroidism with calcium 16.2 mg/dL and intact PTH 1100 pg/mL. There is a hard, fixed 3 cm left neck mass and hoarseness. Sestamibi shows intense uptake in the left neck. What is the most appropriate operative plan?
- A Focused left parathyroidectomy with intraoperative PTH monitoring only
- B En bloc resection of the tumour with ipsilateral thyroid lobectomy and central compartment node dissection ✓
- C Four-gland exploration with total parathyroidectomy and forearm autotransplantation
- D Neck irradiation after biopsy of the mass through a fine needle
Correct answer: B. En bloc resection of the tumour with ipsilateral thyroid lobectomy and central compartment node dissection
Explanation
Very high calcium and PTH with a palpable hard mass and hoarseness from recurrent laryngeal nerve involvement strongly suggest parathyroid carcinoma. Cure depends on initial en bloc resection without capsular breach, including the ipsilateral thyroid lobe and any invaded structures, with central nodal dissection if nodes are involved. Capsule rupture during a focused or shelling-out operation seeds local recurrence, which is the main cause of death. Total parathyroidectomy with autotransplantation is reserved for four-gland hyperplasia, not carcinoma.
Reference: Sabiston Textbook of Surgery, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.