D1 MTE2 Case 4: A case of men - 1

Mr. GR, 40 year man presented to us in 2019 with frequent loose stools and generalised tiredness. He has T2DM (7 years, HbA1c-6.7%), CAD (AWMI-PTCA-2013), well-controlled hypertension and his father had primary hyperparathyroidism (all four removed), nephrolithiasis, T2DM, received renal transplant. Five years back, Mr. GR was diagnosed to have Neuroendocrine tumour following distal pancreatectomy and splenectomy on histopathology. Later in 2019, when his scans were repeated for recurrent abdominal symptoms, the new diagnosis of primary hyperparathyroidism was made (PTH-135 [14-65 pg/mL], Corrected Calcium-11.1 [8.5-10.2 mg/dL], Vitamin D-40 [30-40 ng/mL], 24-hour urinary calcium-328 [100-300 mg/day]). Sestamibi scan showed right inferior parathyroid adenoma. He had abdominal issues with elevated Chromogranin A- 6880 (<93 ng/mL) and Gastrin-730 (0-180 pg/mL), Ga 68-DOTATATE scan revealed overexpressing-somatostatin receptor peripancreatic node and pulmonary metastasis. He was started on Octreotide (2 weeks S/C TID following which monthly LAR injection was given for duration of 12 months. His latest reports showed Chromogranin A-325.7, Gastrin-346, Corrected Calcium-11, PTH-136. Presently, he is asymptomatic, improved with no abdominal issues with moderate glycaemic control (HbA1c-6.7%, FBS-121 mg/dl). How would we move forward with the management of this patient?