Brown tumor in secondary hyperparathyroidism causing acute paraplegia

Brown tumor of the cervical spine with primary hyperparathyroidism: A case report and literature review

RATIONALE

Brown tumor (BT), an uncommon focal lytic bone tumor, is a non-neoplastic and reactive process caused by increased osteoclastic activity and fibroblastic proliferation in primary or secondary hyperparathyroidism. Vertebral tumor causing neural compression is relatively rare, especially in the cervical spine.

PATIENT CONCERNS

A 29-year-old man developed neck pain and arm radicular pain 4 months ago, with the level of serum calcium significantly higher than normal. Computed tomography scan of the cervical spine revealed an expansile lytic lesion occupying the C6 body, left pedicle, and left lamina of C5-6.

DIAGNOSES

Osteoclastoma according to imaging and histopathological results.

INTERVENTIONS

A laminectomy of C5-6 was performed.

OUTCOMES

One month later, he was re-hospitalized due to nausea and vomiting and the serum calcium, was still, kept at a high level. Additionally, the parathormone (PTH) was greatly higher than normal. BT with primary hyperparathyroidism due to the parathyroid tumor was considered. After the surgery of the right parathyroid gland was performed, serum calcium and PTH both decreased, and computed tomography showed good recovery.

LESSONS

BTs might be misdiagnosed as other giant cell tumors, thus when giant cell tumors are considered, serum calcium and PTH examination may be needed to exclude BTs.

Primary hyperparathyroidism presenting with sudden onset paraplegia

A 48-year-old female with long-standing type 2 diabetes mellitus presented with acute onset of bilateral lower limb weakness. She had been previously well and denied any constitutional symptoms. Physical examinations revealed generalized lower limb weakness with bilateral lower limb hypotonia, power of 0 over 5, reduced deep tendon reflexes, and loss of peripheral sensations up to the level of T10. Upper limb functions were normal. Rectal examination showed a lax anal tone and reduced anal grip. Blood investigations showed elevated serum alkaline phosphatase, corrected serum calcium, and parathyroid hormone. Magnetic resonance imaging of the spine revealed an expansile mass at the posterior element of the ninth thoracic vertebrae, causing spinal compression with possible impingement of the right T9 exiting spinal nerve. An urgent surgical decompression and tissue biopsy were performed for stabilization of the spine. Intraoperative findings included spinal cord compression secondary to an epidural tumour mass extending from T9 to T10 disc levels. Histopathological analysis showed a giant cell tumour of the spine. A ^99mTc Sestamibi-SPECT parathyroid scintigraphy showed an ectopic parathyroid adenoma at the left suprasternal region. A diagnosis of Brown tumour secondary to ectopic parathyroid adenoma was made. She underwent an exploratory parathyroidectomy procedure with removal of the ectopic parathyroid gland, which resulted in a normalization of the serum calcium and parathyroid hormone. Unfortunately, her lower limb functions did not return to normal, and she remained paraplegic at 6 months postoperatively.

Missed C5 vertebral brown tumor causing spinal cord compression and myelopathy: A case report and literature review

We aim to report a patient with vertebral brown tumor in the context of a primary hyperparathyroidism presented by shoulder pain. This is the first report of C5 brown tumor involvement in a primary hyperparathyroid patient and emphasizes the consideration of cervical vertebral evaluation in patients with persistent shoulder pain.

Primary hyperparathyroidism with extensive brown tumours and distal humerus fracture-A case report

INTRODUCTION

A brown tumour is benign bony lesion caused by localized, rapid osteoclastic turnover, resulting from hyperparathyroidism. In this report, we present a case of 25-year-old woman with multiple swelling and bone pain. Plain radiographs of the affected bones revealed multiple erosive bone tumours, which were diagnosed as brown tumours associated with primary hyperparathyroidism.

CASE REPORT

A 25 year old female presented with swelling in left elbow since 1 month along with multiple swelling in body. Patient had pain in left elbow after trivial fall. X-ray showed lytic lesion of left elbow with pathological fracture. Biopsy was suggestive of brown tumour of distal humerus.

DISCUSSION

We managed this case with reconstruction of defect with fibula grafting and plating.

CONCLUSION

Pathological fracture in young adult should always be properly investigated. A high index of suspicion is necessary to diagnose unusual presentation of Primary Hyperparathyroidism.

Primary Hyperparathyroidism with Extensive Brown Tumors and Multiple Fractures in a 20-Year-Old Woman

A brown tumor is a benign fibrotic, erosive bony lesion caused by localized, rapid osteoclastic turnover, resulting from hyperparathyroidism. Although brown tumors are one of the most pathognomonic signs of primary hyperparathyroidism, they are rarely seen in clinical practice. In this report, we present a case of 20-year-old woman with recurrent fractures and bone pain. Plain digital radiographs of the affected bones revealed multiple erosive bone tumors, which were finally diagnosed as brown tumors associated with primary hyperparathyroidism due to a parathyroid adenoma. This case shows that multiple, and clinically severe form of brown tumors can even occur in young patients.

Osteoclastomas ('brown tumours') and spinal cord compression: a review

Brown tumours are an uncommon manifestation of primary and secondary hyperparathyroidism. There are numerous case reports of brown tumours arising in various parts of the skeleton. They can therefore present a wide range of clinical manifestations. A recent case highlighted the need for heightened awareness of the diagnosis and prompted a literature review.

Spinal cord compression due to brown tumor

We report a rare case of a vertebral brown tumor causing spinal cord compression and resulting in progressive paraparesis in a 27-year-old female with end-stage renal failure, managed with hemodialysis. Urgent neurosurgical intervention and gross total resection resulted in complete resolution of the symptoms.

Brown tumor of the cervical spines: a case report with literature review

To report a rare case of axis brown tumor and to review literature of cervical spine brown tumor. Brown tumor is a rare bone lesion, incidence less than 5% in primary hyperparathyroidism. It is more common in secondary hyperparathyroidism with up to 13% of cases. Brown tumor reactive lesion forms as a result of disturbed bone remodeling due to long standing increase in parathyroid hormones. Cervical spine involvement is extremely rare, can be confused with serous spine lesions. To date, only four cases of cervical spine involvement have been reported. Three were due to secondary hyperparathyroidism. Only one was reported to involve the axis and was due to secondary hyperparathyroidism. This is the first reported case of axis brown tumor due to primary hyperparathyroidism. A case report of brown tumor is presented. A literature review was conducted by a Medline search of reported cases of brown tumor, key words: brown tumor, osteoclastoma and cervical lesions. The resulting papers were reviewed and cervical spine cases were listed then classified according to the level, cause, and management. Only four previous cases involved the cervical spine. Three were caused by secondary hyperparathyroidism and one was by primary hyperparathyroidism which involved the C6. Our case was the first case of C2 involvement of primary hyperparathyroidism and it was managed conservatively. Brown tumor, a rare spinal tumor that presents with high PTH and giant cells, requires a high level of suspicion.

Brown tumor as an unusual but preventable cause of spinal cord compression: Case report and review of the literature

Brown tumor (BT), also known as osteoclastoma, may appear in the context of primary and secondary hyperparathyroidism. Spinal cord compression due to the BT is extremely rare. We present here an unusual case of BT involving thoracal spine and mandible. A 26-year-old woman, who had been on hemodialysis for chronic renal failure for over 6 years, got admitted with dorsal pain and progressive weakness in her lower extremities and gait disturbances. Neurological examination revealed spastic paraparesis and symmetrically hyperactive tendon reflex in the lower extremities. She had hypoesthesia under T10 level. On physical examination, a swelling on the left side of her jaw was also detected. Magnetic resonance imaging (MRI) showed cord compression due to an extradural mass lesion at T8 level. A computerized tomography (CT) scan showed that this expansile lytic lesion was caused by the collapse of vertebra corpus (T8) at that level. CT of the mandible revealed an expansile lytic lesion on left arm of the mandible. Laboratory findings were nearly normal except parathormone level elevation to 1289 pg/mL (normal 30-70 pg/mL). Ultrasound examination showed enlargement of the parathyroid glands. The patient underwent an emergency decompression and stabilization surgery. The lesion was fragile and reddish in appearance and was easy to aspirate. The tumor was reported as "BT." Her weakness in the lower extremities improved in the early postoperative period. Following surgical intervention, the patient was transferred to nephrology clinic for additional medical treatment.

Vertebral brown tumors causing neurologic compromise

OBJECTIVE

Brown tumors are nonneoplastic lesions that occur only in the setting of hyperparathyroidism. Although vertebral brown tumors are relatively rare pathologic entities, their incidence seems to be on the rise, as evidenced by multiple case reports published during the past four decades. An extensive review of these lesions is lacking in the literature. We present a case of paraparesis secondary to vertebral brown tumor followed by a detailed review of the literature.

METHODS

We performed a review of the literature to locate all reported cases to date of vertebral brown tumors resulting in neurologic sequelae. In addition, we present the case of a 33-year-old female with end-stage renal disease and previous subtotal parathyroidectomy who presented with acute-onset paraparesis from an expansile L1 brown tumor and was treated successfully by laminectomy and bracing.

RESULTS

Thirty cases of vertebral brown tumor resulting in neurologic deficit were located in our literature search. Most occurred in women (63%), those aged 40 to 49 years (27%), and in the thoracic spine (57%). Lesions occurred roughly equally in primary (47%) and secondary (53%) hyperparathyroidism. Most patients demonstrated either symptomatic or radiographic improvement after neurosurgical intervention and/or subtotal or total parathyroidectomy.

CONCLUSION

In patients presenting with a lytic vertebral lesion and known hyperparathyroidism or end-stage renal disease, brown tumor should be considered in the differential diagnosis. In select cases with minimal neurologic symptoms, parathyroidectomy may be warranted prior to neurosurgical intervention.

A haemodialysis patient with back pain: brown tumour as a cause of spinal cord compression under cinacalcet therapy

A 43-year-old haemodialysis patient was admitted to hospital because of paroxysmal pain in the upper abdominal region radiating to the back. Laboratory tests showed severe hyperparathyroidism [intact parathyroid hormone (iPTH) 69 pmol/L; reference range: 1.3-6.8 pmol/L], hypercalcaemia (2.79 mmol/L), hyperphosphataemia (1.6 mmol/L) and elevated serum total alkaline phosphatase (200 U/L). After developing a disturbed sensation and paraesthesia in both feet, epidural compression of the spinal cord was suspected. Magnetic resonance imaging showed a tumour that severely compressed the myelum of the thoracic spine. Histological investigation revealed a brown tumour or osteoclastoma, an erosive bony lesion caused by increased osteoclastic activity and peritrabecular fibrosis. A brown tumour is a benign tumour that is a rare complication of severe renal hyperparathyroidism. The brown tumour developed despite a 1-year treatment of the patient with cinacalcet, which, however, did not result in a major decrease in serum iPTH concentration (from 110 to 69 pmol/L: 37% reduction). Urgent decompressive neurosurgery and subtotal parathyroidectomy resulted in a complete recovery.

Brown tumour of the spine in a renal transplant patient

We report a 30-year-old male who had undergone a renal transplant and suffered with secondary hyperparathyroidism. He presented with back pain and minimal neurological deterioration, caused by a thoracic brown tumour. The imaging findings, surgical treatment of the spinal lesion and outcome are discussed. We also discuss primary medical therapy and suggest a rational approach to further imaging of patients in whom brown tumour is suspected.

Spinal cord compression secondary to brown tumour in a patient on long-term haemodialysis: a case report

Brown tumours may occur secondary to hyperparathyroidism in patients with chronic renal failure (CRF). Diagnosing a spinal brown tumour causing cord compression requires a high index of suspicion. We report a 65-year-old woman, who had been on haemodialysis for CRF for over 10 years, who presented with leg weakness and back pain over the thoracolumbar junction. She had a brown tumour at T8 causing subacute spinal cord compression. Ambulation was regained after surgical decompression and stabilisation. Adherence to the National Kidney Foundation guidelines in the management of patients with CRF may prevent renal osteodystrophy. Treatment of spinal brown tumour depends on the severity of the neurological deficit. Remineralization is expected after correction of the parathyroid level, thus negating the need for total excision of the parathyroid glands.

Spinal cord compression caused by a brown tumor at the cervicothoracic junction

BACKGROUND CONTEXT

Brown tumors are classic benign skeletal manifestations of hyperparathyroidism, but the spine involvement is very rare. Spinal reconstruction in these patients is controversial because of the severe osteoporosis and impaired bone healing. Of the reported 12 cases of spinal brown tumors in the literature, only in 5 were reconstructions with bone graft used.

PURPOSE

To describe our management in a patient with brown tumor and also to review the previous published cases.

STUDY DESIGN

Case report.

METHODS

A case of a brown tumor in the T1 vertebra of a 72-year-old male patient is described. He had a previous diagnosis of secondary hyperthyroidism caused by renal failure. First, posterior transpedicular open biopsy was performed for the diagnosis and also for the decompression of the root causing brachialgia. After the diagnosis of a brown tumor, the patient was reoperated through anterior approach for total tumor removal and reconstruction of the spine. An autolog 3-cortical iliac crest strut graft was used for fusion, and medical treatment of hyperparathyroidism was given immediately after the operation. Decompression of spinal canal and fusion of bone graft was shown by a computed tomography scan 1 year after the operation.

RESULTS

Complete resolution of the complaints of the patient and fusion of the graft were achieved.

CONCLUSION

The determination of a spinal tumor in a patient with renal failure and hyperparathyroidism should bring to mind the probability of a brown tumor. Although it is of a benign nature, it can cause severe neurologic deficit because of spinal compression. The recommended treatment modality is surgical resection of the tumor, spinal reconstruction, and aggressive treatment of hyperparathyroidism both with parathyroidectomy and medically.

Unusual spinal manifestation in secondary hyperparathyroidism: a case report

STUDY DESIGN

Case report.

OBJECTIVES

To describe an unusual spinal manifestation of secondary hyperparathyroidism in a 29-year-old woman and discuss the pathologic basis of the disease and evaluate the response to treatment.

SUMMARY OF BACKGROUND DATA

Extraskeletal tumoral calcification (i.e., tumoral calcinosis, tumoral calcinosis-like lesion, calcifying pseudoneoplasms) is an uncommon entity associated with secondary hyperparathyroidism. Involvement of the cervical spine with this tumor causing neural compression is extremely rare. Only a few cases have been reported in literature and none with a concomitant presence of brown tumors.

METHODS

A 29-year-old woman presented with upper back pain with tingling and weakness in the left hand. She had been on dialysis for 5 years following renal failure. She had a partial parathyroidectomy for hyperparathyroidism a year ago. Para vertebral calcification eroding the posterior elements of C6-T2 and abutting the dura and neural foramens was seen on a CT scan. There were numerous lytic defects of the thoracic and lumbar vertebral bodies, most notable at L4, suggesting focal brown tumors. An MRI scan of the spine demonstrated a large heterogeneously hypointense lesion of the cervicothoracic spine, which remained hypointense on T2 images. A cervicothoracic decompression and spinal stabilization from the front and back was performed. A pathologic diagnosis of tumoral calcinosis-like lesion was confirmed.

RESULT

Following surgery, the patient recovered neurologically and subsequently underwent total parathyroidectomy. Presently, her bone lesions have healed.

CONCLUSION

Hyperparathyroidism may cause tumoral calcinosis-like lesions in the spine. An early spinal decompression followed with parathyroidectomy leads to remission of symptoms.

Cauda equina compression revealing brown tumor of the spine in a long-term hemodialysis patient

Brown tumors, or osteoclastomas, are erosive bony lesions arising as a complication of hyperparathyroidism (HPT). In patients with end-stage renal disease (ESRD), brown tumors are classic skeletal manifestations usually seen in severe forms of secondary HPT. However, involvement of the spine is considered extremely rare. We report a long-term hemodialysis case, in which cauda equina compression developed due to a sacral brown tumor. A decompressive surgery and subtotal parathyroidectomy were indicated to preserve neurologic function, and to ensure remineralization of the lesion. This case illustrates that, though rare, brown tumors should be considered in uremic patients with neurological symptoms. Emergent decompressive surgery is required to remove pressure on neurological structures and to stabilize the spine.

Sellar-parasellar brown tumor: case report and review of literature

Brown tumors are the end stage of primary or secondary hyperparathyroidism. Such lesions are rare because hyperparathyroidism is now usually diagnosed and treated before they develop. Skeletal bone is most frequently involved, whereas sellar-parasellar involvement is extremely rare. We report a patient with a brown tumor involving the sellar-parasellar region associated with primary hyperparathyroidism. The patient's clinical history and biochemical and radiological tests were used for the diagnosis. Excision of the sellar-parasellar mass enabled histopathological confirmation and surgical decompression of neural structures. After the transsphenoidal surgery, excision of a parathyroid adenoma normalized the patient's metabolic status. Brown tumors are rarely associated with complications but occasionally may compress neural structures such as the optic nerve as they enlarge.

Brown tumor of the spine and progressive paraplegia in a hemodialysis patient

STUDY DESIGN

Case report.

OBJECTIVE

To describe the radiographic features and management of spinal brown tumor and to document tumor mineralization after parathyroidectomy.

SUMMARY OF BACKGROUND DATA

Brown tumors are classic skeletal manifestations of hyperparathyroidism usually seen in severe forms. They are increasingly rare because hyperparathyroidism is now diagnosed and treated at an early stage.

METHODS

A case of brown tumor of the spine in a 37-year-old woman on chronic hemodialysis is described. The imaging findings before and after parathyroidectomy are discussed.

RESULTS

In a woman on chronic hemodialysis, a brown tumor of T8 caused acute spinal cord compression with paraplegia. Magnetic resonance imaging provided an accurate evaluation of the lesion, and needle biopsy confirmed the diagnosis. Emergent surgery was needed to relieve the spinal compression and stabilize the spine. The vertebral lesion underwent remineralization after parathyroidectomy.

CONCLUSION

Brown tumor is a benign tumor that resolves after parathyroidectomy. When brown tumor arises in the spine, surgery may be needed to preserve neurologic function.

Chronic renal failure causing brown tumors and myelopathy. Case report and review of pathophysiology and treatment

Brown tumors (osteoclastomas) are histologically benign lesions that are caused by primary or secondary hyperparathyroidism. Secondary hyperparathyroidism is a frequent complication of chronic renal failure. Skeletal brown tumors are relatively uncommon, and brown tumors that involve the spine are considered very rare. The authors present the case of a 37-year-old woman with systemic lupus erythematosus and hemodialysis-dependent anuric renal failure, in whom spinal cord compression developed due to a brown tumor and pathological fracture at T-9. The patient underwent transthoracic decompressive surgery and spinal reconstruction in which cadaveric femoral allograft and instrumentation were used. Brown tumors of the vertebral column require surgical treatment if medical therapy and parathyroidectomy fail to halt their progression or if acute neurological deterioration occurs. In patients with renal failure bone healing is delayed and there is an increased risk that healing will fail because the metabolic derangements can result in severe osteoporosis. Surgical reconstruction of the spine may require the use of augmentation with instrumentation and aggressive treatment of hyperparathyroidism to achieve successful outcomes.

Spinal tumour due to primary hyperparathyroidism causing sciatica: case report

We report a unilateral intraspinal cyst-like lesion adjacent to the lamina and facet joint at the L4-L5 level producing sciatica. Histological examination revealed multinucleate giant cells suggesting a brown tumour. Further studies disclosed primary hyperparathyroidism, whose first manifestation was the lumbar nerve root compression. Previous cases of compression of neural structures by spinal brown tumours are reviewed and a radiological differential diagnosis is presented.

Paraparesis due to massive ectopic paravertebral calcification in a patient on maintenance hemodialysis

Secondary hyperparathyroidism is ubiquitous in patients with end-stage renal disease who are on dialysis. We report a dialysis patient with an unusual manifestation of hyperparathyroidism. Initially, the patient was misdiagnosed to have clavicular osteomyelitis. The underlying hyperparathyroidism was not recognized, only to be discovered later, when the patient presented with spastic paraplegia and massive ectopic calcification in the cervical spine. The patient made a complete recovery following surgical resection and parathyroidectomy.

Neurologic complications of thyroid and parathyroid disease

Common thyroid and parathyroid disorders present with reversible neurologic signs and symptoms affecting the central and peripheral nervous system, musculature, and mental function. Patients with thyrotoxicosis may have myopathy, spasticity, seizures, and multiple psychiatric symptoms. A deficiency of thyroid hormone also causes muscle weakness and may be accompanied by reversible muscle hypertrophy or movement disorders. The chronic hypercalcemia that develops secondary to hyperparathyroidism produces many psychiatric and cognitive symptoms, as well as a reversible myopathy. Calcium deficiency leads to neuromuscular irritability, paresthesias, and tetany. Psychiatric disorders are also common in this disorder.

Progress of brown tumors in patients with chronic renal insufficiency undergoing dialysis

In a group of 73 patients, affected by chronic renal insufficiency, whose skeleton was periodically checked, three cases of brown tumors were found. These cases demonstrated a variety of locations that were involved, especially the pelvis, ribs and mandible. During therapeutic treatment the brown tumors presented a different behavior; while some lesions tended toward complete sclerosis, others increased in size and in both instances new lesions appeared. Parathyroidectomy, carried out in two patients, determined a definitive sclerosis of these lesions. Brown tumors also correlate with high PTH levels and with lesions from osteitis fibrosa.

Osteitis fibrosa cystica (brown tumor) of the spine with cord compression: report of a case with needle aspiration biopsy findings

A case of osteitis fibrosa cystica or brown tumor of bone in a patient presenting with acute spinal cord compression that was suggested initially by needle aspiration biopsy of the spine is described. Following the aspiration biopsy, excision of vertebral lesions, cord decompression, and spinal fusion were successfully performed. A parathyroid adenoma was subsequently identified and also resected. Along with the diagnosis of malignancy, the presence of hyperparathyroidism with osteitis fibrosa cystica should be considered in a patient presenting with lytic lesions in bone, especially if they are associated with hypercalcemia. Serum parathormone level determination is usually diagnostic of hyperparathyroidism, but this test has a 7-10-day turnaround time. Preoperative needle aspiration biopsy is a safe and rapid method of diagnosing osteitis fibrosa cystica and may be of critical importance in a patient with acute and progressive symptoms such as cord compression.

Paraplegia caused by brown tumor in primary hyperparathyroidism. Case report

A brown tumor is a secondary disorder of bone associated with hyperparathyroidism that arises predominantly in the metacarpals, phalanges, jaw, pelvis, or femur. Rarely does this tumor involve the spine. The authors describe a case of brown tumor in primary hyperparathyroidism, causing spinal cord compression. The first step in diagnosing this lesion in an unusual site is a high index of suspicion. Essentially, this tumor is benign but emergency surgery for tumor removal is recommended in patients showing acute spinal cord compression.