A 48-year-old man presents with serum calcium 15.2 mg/dL, intact PTH 1050 pg/mL (upper limit 65), a 3 cm hard, fixed nodule at the lower pole of the right thyroid lobe, and recurrent nephrolithiasis. Neck ultrasound suggests invasion into adjacent soft tissue. Fine-needle aspiration is reported as suspicious for parathyroid neoplasm. The most appropriate next step is:

• A En bloc resection of the lesion with ipsilateral thyroid lobectomy without breaching the capsule ✓
• B Focused minimally invasive parathyroidectomy with intraoperative PTH monitoring
• C Neck dissection followed by adjuvant radioactive iodine therapy
• D Percutaneous ethanol ablation followed by annual surveillance

Explanation

Marked hypercalcaemia above 14 mg/dL, PTH three to ten times the upper limit, a palpable hard mass in the setting of hyperparathyroidism, and local invasion are classic for parathyroid carcinoma. Curative treatment is en bloc resection including the ipsilateral thyroid lobe and any invaded structures, performed without rupturing the capsule because capsular breach seeds recurrent disease. Minimally invasive focused surgery risks capsular fracture, and there is no role for radioactive iodine or ethanol ablation in this malignancy.

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

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Written and medically reviewed by the StethoPrep medical team.