Tc99m-sestamibi uptake in osteitis fibrosa cystica simulating metastatic bone disease

Primary Hyperparathyroidism With Brown Tumor of the Mandible Misdiagnosed as a Giant Cell Tumor: A Case Report

In this case study, we present an incidentally discovered giant cell granuloma, which, upon detailed investigation, led to an unexpected diagnosis. A 36-year-old woman exhibited a bone lesion in the right retromolar trigone area, initially suspected of being malignant. However, histopathological examination revealed a giant cell tumor of bone. Further biochemical profiling, including serum calcium, phosphorus, and parathyroid hormone (PTH) levels, showed elevated PTH and hypercalcemia, prompting consideration of primary hyperparathyroidism and the diagnosis of a brown tumor due to this condition. This case underscores the importance of considering brown tumors associated with primary hyperparathyroidism as a potential differential diagnosis in patients with lytic bone lesions.

Osteitis Fibrosis Cystica: Classical Case Report of an Uncommon Presentation in a Young Female

Osteitis fibrosa cystica (OFC) is a skeletal disease related to long standing, end-stage hyperparathyroidism. However, nowadays hypercalcemia due to primary or secondary hyperparathyroidism can often be detected early by laboratory screening and imaging modalities; consequentially the frequency of osteitis fibrosa cystica has drastically declined. OFC, also termed as Brown tumor, can mimic primary bone tumors clinically, which often leads to misdiagnosis and inappropriate management. Moreover due to its rarity, it is usually not considered initially in the differential diagnosis of bony tumors. Case presentation: This is the case of a 19-year-old female, who presented with pain over the left ankle region for 3 months. The biochemical screening revealed a picture consistent with primary hyperparathyroidism and the radiologically proven to be left inferior parathyroid adenoma. She underwent excision of the primary parathyroid adenoma, and gradual regression of symptoms was noted postoperatively. Osteitis fibrosa cystica is a rare manifestation of hyperparathtyroidism, which has become a forgotten entity lately due to early identification of hypercalcaemia by modern techniques. A delay in the diagnosis of parathyroid adenoma results in manifestations that can be avoided. The diagnosis of OFC requires a high degree of clinical suspicion. When hypersecretion of PTH is corrected, spontaneous regression of the lesion is expected.

Multiple Brown Tumors Secondary to Parathyroid Carcinoma: A Challenging Diagnosis

Parathyroid carcinoma is an extremely rare endocrine neoplasm that accounts for less than 1% of the cases of primary hyperparathyroidism (PHPT). Continuous exposure to high levels of parathyroid hormone (PTH) induces an increase in bone remodeling and patients may present with osteitis fibrosa cystica, which is characterized by subperiosteal resorption of the phalanges, diffuse osteopenia, salt and pepper appearance of the skull, bone cysts, and brown tumors. Brown tumors occur in less than 5% of all patients with any form of hyperparathyroidism. Due to similar clinical, radiographic, and histological appearance, differential diagnosis of brown tumors includes primary and secondary bone tumors. We report a case of a 67-year-old female diagnosed with multiple osteolytic lesions initially thought to be bone metastasis of thyroid carcinoma. Further work-up led to the diagnosis of brown tumors due to parathyroid carcinoma. We want to emphasize the inclusion of osteitis fibrosa cystic in the differential diagnosis of osteolytic lesions and the need to perform serum calcium and PTH measurements when investigating these lesions.

Diagnosis and treatment of primary hyperparathyroidism with pathological fracture of the limbs: A retrospective observational study

Primary hyperparathyroidism (PHPT) with pathological fracture is rare, and the early symptoms of PHPT lack specificity, leading to misdiagnosis. Therefore, this study aimed to summarize the clinical characteristics and treatment of PHPT patients with pathological fractures and to improve the attention of orthopedic clinicians to PHPT. It is a retrospective study, 2226 patients with hyperparathyroidism in our hospital from 2009 to 2019 were screened, excluding secondary hyperparathyroidism and patients without limb fracture, and the remaining 20 patients with PHPT accompanied by pathological fractures were finally analyzed. Parathyroid hormone (PTH) and calcium levels were compared on the first postoperative day, and the prognosis of the patients was assessed by bone mineral density and Visual Analogue Scale scores at 3 and 12 months postoperatively. The early symptoms of PHPT patients in this study included urinary calculi (80%), bone pain (30%), and digestive tract symptoms (25%). Fourteen (70%) cases were misdiagnosed at the initial diagnosis. After parathyroidectomy, the blood calcium and PTH levels decreased significantly in all patients (P < .05). For the treatment of fracture, 9 of the patients underwent surgical treatment of the fracture, while the remaining patients received splint external fixation. The follow-up time was 4.60 ± 0.62 years (1-10 years). All patients recovered well from the fracture, the symptoms of systemic bone pain were markedly improved, and bone mineral density was significantly improved after surgery. Orthopedic surgeons need to avoid misdiagnosis and pay attention to the early symptoms in PHPT patients with pathological fracture, and better therapeutic effects can be obtained by combining parathyroidectomy with fractures fixation.

A Rare Case of Concomitant Maxilla and Mandible Brown Tumours, Papillary Thyroid Carcinoma, Parathyroid Adenoma, and Osteitis Fibrosa Cystica

Objective. The brown tumour of hyperparathyroidism is a result of a metabolic disorder caused by primary hyperparathyroidism. Report. We described a case of a 37-year-old female patient presenting bimaxillary intraoral lesions and swelling in the neck. Incisional biopsy of the oral lesion was performed and histopathological examination revealed a central giant cell lesion composed by intense haemorrhagic exudate, abundant presence of giant cells, and areas with hemosiderin pigment. The patient also presented high levels of serum calcium and parathyroid hormone, hyperfunctioning parathyroid tissue, bilateral parenchymal nephropathy, and densitometry lower than expected, showing an advanced stage of osteitis fibrosa cystica. Synchronous parathyroid adenoma and papillary thyroid carcinoma were confirmed by imaging exams and histopathologically. Conclusion. The composition of all the clinical, pathological, and imaging findings led to the final diagnosis of brown tumour of hyperparathyroidism. The occurrence of parathyroid adenoma, papillary thyroid carcinoma, and brown tumours of hyperparathyroidism in their late stage (osteitis fibrosa cystica) associated with oral brown tumours involving the mandible and maxilla is extremely rare.

Diagnosis and management of primary hyperparathyroidism--a scientific statement from the Department of Bone Metabolism, the Brazilian Society for Endocrinology and Metabolism

OBJECTIVE

To conduct a literature review on the diagnosis and management of primary hyperparathyroidism including the classical hipercalcemic form as well as the normocalcemic variant.

MATERIALS AND METHODS

This scientific statement was generated by a request from the Brazilian Medical Association (AMB) to the Brazilian Society for Endocrinology as part of its Clinical Practice Guidelines program. Articles were identified by searching in PubMed and Cochrane databases as well as abstracts presented at the Endocrine Society, Brazilian Society for Endocrinology Annual Meetings and the American Society for Bone and Mineral Research Annual Meeting during the last 5 years. Grading quality of evidence and strength of recommendation were adapted from the first report of the Oxford Centre for Evidence-based Medicine. All grades of recommendation, including "D", are based on scientific evidence. The differences between A, B, C and D, are due exclusively to the methods employed in generating evidence.

CONCLUSION

We present a scientific statement on primary hyperparathyroidism providing the level of evidence and the degree of recommendation regarding causes, clinical presentation as well as surgical and medical treatment.

(99m)Tc-MIBI Whole Body Scan: A Potentially Useful Technique for Evaluating Metabolic Bone Disease

Metabolic bone disease due to hyperparathyroidism is characterized by increased bone resorption and new bone formation. ^99mTc- hexakis-2-methoxyisobutylisonitrile (^99mTc MIBI) accumulation is controlled by metabolic function and cell viability. To investigate, for the first time, the potential of whole body ^99mTc MIBI scan for detecting, visually and with the aid of quantitative analysis, bony changes associated with hyperparathyroidism. Eighty-six patients with hyperparathyroidism, referred routinely for parathyroid localization, were included in this case-control prospective study. Each patient was injected with 20-25 mCi of ^99mTc MIBI. Routine anterior cervico-thoracic images were obtained for parathyroid localization. Two extra whole body images were acquired and assessed visually and by drawing regions of interest over the mandible, sternum, femur, humeri, spine, and the soft tissue adjacent to the bone. The ratios of bone to soft tissue were calculated and compared to ratios drawn in a control group routinely referred for cardiac imaging and injected with ^99mTc MIBI, after confirming the absence of any bone disease. The visual interpretation of the scans showed 48 patients to have increased bone uptake. Quantitative assessment showed significant difference between the mean ratios of the case and control groups. The Kruskal-Wallis test showed significant agreement between visual and quantitative ratios drawn from delayed right and left femora and left humerus images (P < 0.05). ^99mTc MIBI whole body imaging is a potentially useful technique for assessing metabolic bone disease associated with hyperparathyroidism. Quantitative analysis helped in confirming the visual findings.

Successful treatment of osteitis fibrosa cystica from primary hyperparathyroidism

Osteitis Fibrosa Cystica (OFC) is defined as the classic skeletal manifestation of advanced primary hyperparathyroidism. With the increased detection by means of routine calcium screening, the clinical profile of primary hyperparathyroidism in Western countries has shifted from symptomatic disease to one with subtle or no specific symptoms (“asymptomatic” primary hyperparathyroidism). The authors describe a classical feature of advanced primary hyperparathyroidism due to a parathyroid adenoma and its successful treatment.

Primary hyperparathyroidism diagnosed after surgical ablation of a costal mass mistaken for giant-cell bone tumor: a case report

INTRODUCTION

Primary hyperparathyroidism is a common endocrine disorder characterized by elevated parathyroid hormone levels, which cause continuous osteoclastic bone resorption. Giant cell tumor of bone is an expansile osteolytic tumor that contains numerous osteoclast-like giant cells. There are many similarities in the radiological and histological features of giant cell tumor of bone and brown tumor. This is a rare benign focal osteolytic process most commonly caused by hyperparathyroidism.

CASE PRESENTATION

We report the unusual case of a 40-year-old Caucasian woman in which primary hyperparathyroidism was diagnosed after surgical ablation of a costal mass. The mass was suspected of being neoplastic and histopathology was compatible with a giant cell tumor of bone. On the basis of the biochemical results (including serum calcium, phosphorous and intact parathyroid hormone levels) primary hyperparathyroidism was suspected and a brown tumor secondary to refractory hyperparathyroidism was diagnosed.

CONCLUSIONS

Since giant cell tumor is a bone neoplasm that has major implications for the patient, the standard laboratory tests in patients with bone lesions are important for a correct diagnosis.

Mediastinal parathyroid carcinoma presenting with severe skeletal manifestations

Parathyroid carcinoma is a rare malignancy, accounting for about 1% of primary hyperparathyroidism. We report the case of a 23-year-old man who presented with poorly united mid-shaft fracture of the left femur with severe hypercalcaemia in the setting of 99 mTc sestamibi-avid lesions in the mediastinal and thoracic vertebrae. The patient underwent surgery, and histopathology revealed a low-grade parathyroid carcinoma. After surgery, the patient developed severe hungry bone syndrome requiring intensive calcium, magnesium and active vitamin D supplementation. A review of the literature was undertaken with regards to mediastinal parathyroid carcinoma, management of refractory hypercalcaemia in this setting and hungry bone syndrome.

Multiple brown tumors in primary hyperparathyroidism caused by an adenoma mimicking metastatic bone disease with false positive results on computed tomography and Tc-99m sestamibi imaging: MR findings

We encountered an unusual case of hyperparathyroidism with both hemosiderin deposits on the ribs and low intensity on T2-weighted magnetic resonance imaging (MRI) caused by a parathyroid adenoma with multiple brown tumors that mimicked metastatic bone tumor due to false positive results on computed tomography (CT) and Tc-99m sestamibi (MIBI) imaging. The patient, a middle-aged woman, had very high serum levels of calcium (14.1 mg/dl), alkaline phosphatase (9,369 IU/l) and intact-PTH (12,400 pg/ml), and a large tumor (2.5 cm in diameter) in the lower portion of the left lobe of the thyroid. Plain X-ray revealed a soft tumor in the left chest wall. On CT scan, there were multiple destructive masses in the ribs, including large intramedullary masses on both 3rd ribs. On MIBI scintigraphy, there was strong late uptake in the lower portion of the left cervical region, both 3rd ribs, and the left 7th, 8th, and 10th ribs. T2-weighted image MRI scans showed that both 3rd ribs had a low intensity with hemosiderin deposits. These findings suggested that the patient had hyperparathyroidism with multiple bone metastases due to carcinoma of the parathyroid gland. However, on pathology, the resected tumor of lower portion of the left lobe of thyroid was diagnosed as a parathyroid adenoma, and the tumors of the left 3rd and 7th ribs, as well as the right 2nd rib, were shown to be brown tumors. After resection, the patient's serum levels of calcium, alkaline phosphatase, and intact-PTH normalized. At 1.5-years follow-up, CT, MIBI, and MRI scans showed no abnormal findings. It is necessary to determine whether MRI can be used to distinguish between brown tumors and metastases caused by carcinoma of the parathyroid gland.

From mild to severe primary hyperparathyroidism: the Brazilian experience

Primary hyperparathyroidism often presents as an asymptomatic disorder. In our institution, routine serum calcium measurements have now been used as part of medical examination for 23 years. Out of 124 patients consecutively seen at our institution, 47% presented with no symptoms related to the disease, while 25% presented with severe skeletal involvement and osteitis fibrosa cystica, 25% with renal stone disease without overt bone involvement, and 2% with the typical neuropsychiatric syndrome. This same pattern is seen in the city of São Paulo. In severe disease pathological fractures are frequently seen, especially in long bones of the lower extremities, and also loss of lamina dura of the teeth and salt-and-pepper appearance of the skull. Bone mineral density is extremely low in these patients but usually show remarkable recovery following surgical cure. Serum PTH and bone markers are considerable higher in severely affected patients, who also have a high rate of vitamin D deficiency, and the parathyroid lesion is easier located compared with asymptomatic patients. From pathological specimens 87% had histological confirmation of a single adenoma, 6.4% multiple gland hyperplasia and 3.8% carcinoma.

Hammers and nails: a report

A case report where parathyroid bone disease simulates bone metastases. Subsequent treatment of underlying hyperparathyroidism causes a marked improvement in bone disease, leading to a review of the initial diagnosis.