A 45-year-old man is diagnosed with primary hyperparathyroidism. Serum calcium is 12.1 mg/dL, PTH is 110 pg/mL. Sestamibi scan and neck ultrasound are both negative for any parathyroid abnormality. He has no family history. What is the most appropriate next step in management?

• A Observe with annual calcium and creatinine monitoring
• B Perform four-gland exploration at a center experienced in reoperative parathyroid surgery
• C Obtain a four-dimensional CT (4D-CT) of the neck ✓
• D Start cinacalcet therapy long-term

Explanation

When first-line localization studies (sestamibi and ultrasound) are negative in biochemically confirmed primary hyperparathyroidism, four-dimensional CT of the neck is the most sensitive second-line imaging modality, detecting parathyroid adenomas with sensitivity approaching 88% and identifying ectopic locations such as mediastinum or undescended glands. Observation is inappropriate with calcium above 1 mg/dL above normal. Surgery should proceed after localization. Cinacalcet is a medical option but is not first-line definitive management in a surgical candidate with classic hypercalcemia.

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

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Written and medically reviewed by the StethoPrep medical team.