Primary hyperparathyroidism presenting as multiple giant cell lesions

A case of giant cell lesion as an initial feature of primary hyperparathyroidism is presented. A 55-year-old woman reported with a complaint of swelling and occasional pain in the upper-left posterior region with 2 months' duration. The diagnosis of a giant cell lesion with primary hyperparathyroidism was confirmed on the basis of radiological, biochemical, and histopathological investigative procedures.

Brown tumor with fluid-fluid levels in a patient with primary hyperparathyroidism: radiological findings

We report a case of a brown tumor with fluid-fluid levels in a patient with primary hyperparathyroidism. A 19-year-old woman presented with a 3-month history of pain in the left pubic region. The laboratory data showed elevated serum calcium and intact parathyroid hormone, confirming the diagnosis of primary hyperparathyroidism. Plain radiography and computed tomography (CT) showed an expansile lytic lesion of the superior ramus of the left pubis. The cortex was thinned. On magnetic resonance (MR) images, the lesion was solid and cystic. The solid area of the lesion showed heterogeneous low to intermediate signal intensity on T1-weighted images and heterogeneous low to high signal intensity on T2-weighted images. The cystic area showed several fluid-fluid levels on T2-weighted images. Dynamic contrast-enhanced MR images after administration of Gd-DTPA showed marked, early enhancement of the solid area of the lesion. A delayed image showed prolonged enhancement of the solid area and enhancement of the septa and walls of the cystic area. Histopathology of a biopsy specimen showed fibroblastic proliferation, abundant giant cells, and focal hemosiderin deposition, which supported the diagnosis of a brown tumor. After removing the parathyroid adenoma, the brown tumor regressed and became sclerotic on radiographs.

Brown tumor of the mandible associated with secondary hyperparathyroidism: a case report and review of the literature

Brown tumors are rare lesions that can develop in persistent cases of hyperparathyroidism (HPT). Therefore, identification of these lesions by diagnostic imaging is important during the follow-up of patients with HPT. This report describes a 45-year-old woman who developed HPT-induced brown tumors that appeared initially as an oral lesion. The diagnosis, treatment, and control of the disease--as well as the histopathological characteristics--are emphasized.

Brown tumor of the facial bones: case report and literature review

Brown tumor, an uncommon focal giant-cell lesion, arises as a direct result of the effect of parathyroid hormone on bone tissue inpatients with hyperparathyroidism. The initial treatment involves the correction of hyperparathyroidism, which usually leads to tumor regression. We report a case of brown tumor of the right nasal fossa in a 71-year-old woman. The tumor had caused nasal obstruction and epistaxis. Laboratory evaluation revealed that the patient had primary hyperparathyroidism. Anatomicopathologic investigation revealed the presence of a giant-cell tumor We performed a partial parathyroidectomy, but the tumor in the right nasal fossa failed to regress. One year later we performed surgical resection of the lesion. The patient recovered uneventfully, and she remained asymptomatic and recurrence-free at the 1-year follow-up. Facial lesions with histologic features of a giant-cell tumor should be evaluated from a systemic standpoint. Hyperparathyroidism should always be investigated by laboratory tests because most affected patients are asymptomatic. Surgical resection of a brown tumor should be considered if the mass does not regress after correction of the inciting hyperparathyroidism or if the patient is highly symptomatic.

Giant cell tumours of the maxilla and tibia presenting concurrently as an initial manifestation of primary parathyroid adenoma

A 14 years female of Afghan origin reported with maxillofacial and tibia growths causing progressive deformities since nine months, both were giant cell tumours on histopathology. Serum calcium was normal, but the parathyroid hormone was exaggerated (678 pg/ml). Ultrasound indicated and Tc-99m Setamibi scan confirmed a left lower parathyroid lesion. A 4cm length mass was identified, removed and proved to be a parathyroid adenoma. Two weeks later a subtotal maxillectomy and six weeks later anterior wedge osteotomy of the tibia were carried out. Serum parathyroid hormone level normalized.

Calcaneal brown tumor with primary hyperparathyroidism caused by parathyroid carcinoma: an atypical localization

Brown tumors are one of the characteristics of primary hyperparathyroidism, although, in some cases, they are noted with secondary hyperparathyroidism as well. The authors present a case of a 50-year-old woman with primary hyperparathyroidism caused by parathyroid carcinoma with an unusual location of a brown tumor in the calcaneus. She first presented with pain and swelling over the heel and ankle, and the diagnosis was suspected by radiographs. Biopsy of the calcaneal lesion confirmed a brown tumor. After the parathyroid lesion was removed surgically, her symptoms were relieved. The calcaneal lesion was treated with immobilization of the foot.

Giant cell tumor and Paget's disease of bone in one family: geographic clustering

Giant cell tumor is a rare complication of Paget's disease of bone. Typically, this tumor occurs in the case of polyostotic disease and only in pagetic bones. This tumor rarely has been seen in multiple family members who have Paget's disease, although Paget's bone disease clearly has a hereditary component. Our report documents four cases of polyostotic Paget's bone disease complicated by benign giant cell tumor. In two patients, the giant cell tumor also was multifocal. All patients were from one family. They were born in Avellino and reside in Campania, a Southern Italian region. The ancestors of the patients with familial giant cell tumor in Paget's bone disease were born in the same geographic area. These data suggest that a combination of environmental and genetic factors could be responsible for linkage of the patients born in Avellino with this neoplasm that is highly unusual in patients with Paget's disease of bone.

Giant cell tumor of bone. The role of fibroblast growth factor 3 positive mesenchymal stem cells in its pathogenesis

OBJECTIVES

Giant cell tumor of bone is typified by massive infiltration of a bland neoplastic stroma by osteoclasts and monocyte progenitors. The current study aimed at evaluating the nature of the neoplastic cells and the mechanisms underlying the massive giant cell recruitment.

METHODS

Five different giant cell tumors were evaluated by immunohistochemistry, and explant cell cultures were established from the same tumors. Antigen expression profiles of both the tumors and the derived cultures were assessed. In order to determine if the mesenchymal cells are capable of differentiating into mature osteoblasts, retinoic acid was added to cell cultures and osteocalcin and alkaline phosphatase levels were measured. The proliferative effects of the mesenchymal cells on histiocyte-like cells were evaluated using the U-937 cell line.

RESULTS

A large stromal subpopulation expresses fibroblast growth factor receptor 3 (FGF-R3), indicating a mesenchymal origin of these cells. Few cells express bone- or cartilage-specific markers. Cell cultures are predominated by mesenchymal cells, as indicated by a strong staining by FGF R3. Retinoic acid induces osteoblastic differentiation, i.e. osteocalcin expression and alkaline phosphatase production. Conditioned medium of giant-cell-tumor-derived stromal cell cultures induces proliferation of U-937 cells, derived from histiocytic lymphoma. Papain digestion and dialysis of the conditioned media indicates the effector molecule to be a protein over 40 kD in size. The giant cell tumors as well as stromal cell cultures derived from giant cell tumors express osteoprotegerin ligand, the osteoclast activator.

CONCLUSIONS

The neoplastic stromal spindle-shaped subpopulation of cells in giant cell tumors are mesenchymal stem cells capable of inducing histiocyte proliferation. Retinoid acid is capable of inducing differentiation of the cells into mature osteoblasts. This should be further investigated in an in vivo model to ascertain whether induction of differentiation will prevent bone loss and retard tumor progression.

[Giant-cell tumor of the bone]

The giant-cell tumor of bone (GCT) is an aggressive benign, potentially malignant lesion, which biological behaviour is unpredictable. Its aggressivity is usually increasing through the recurrences and is related to the mitotic activity, the excessive metalloproteinase expression and to the alterations in different oncogens of the tumor cells. Statistically, 80% of the GCT-s have a benign course, with a local recurrence rate of 10-50%; about 10% of GCT-s undergo malignant transformation through their recurrences and 1-4% give pulmonary metastases even in case of a benign histology. Despite of the frequent recurrences, adequate treatment results in 96% to 98% cure in patients with GCT. The goal of surgery should be both in primary and recurrent cases: joint-sparing and careful curettage with use of adjuvants (bone cement and phenol, etc.) for decreasing the rate of recurrences. Resection is only in case of extensive joint destruction or malignancy indicated. Radiotherapy with modern supervoltage equipment minimalized the occurrence of secondary malignant transformation, however, its use is only in locations difficult for surgery (vertebra, sacrum, pelvis) recommended.

Malignancy in giant cell tumor of bone

BACKGROUND

The term malignant giant cell tumor embraces multiple entities and therefore can be confusing. The goals of the current study were to define the clinicopathologic and histologic features of malignancy in giant cell tumors and to clarify the terminology.

METHODS

The authors reviewed all cases from the Rizzoli Institute (Bologna, Italy) of primary (PMGCT) and secondary (SMGCT) malignancy in giant cell tumors. PMGCT is a high-grade sarcoma that arises side by side with benign giant cell tumors. SMGCT is a high-grade sarcoma that occurs at the sites of previously treated giant cell tumors of bone.

RESULTS

The authors report 5 PMGCTs and 12 SMGCTs; half of the SMGCTs were postradiation sarcomas. Patient age ranged from 20 to 68 years (median, 62 years) for PMGCT and from 30 to 77 years (median, 40 years) for SMGCT. The average latent period between diagnosis of giant cell tumor and diagnosis of SMGCT was 9 years (range, 3-15 years) for patients with postradiation SMGCT and 19 years (range, 7-28 years) for patients with SMGCT resulting from spontaneous transformation. The histologic classification of high-grade sarcomas in the PMGCT group was osteosarcoma in four cases and malignant fibrous histiocytoma in one case. In the SMGCT group, the histologic classification was osteosarcoma in nine cases, fibrosarcoma in two cases, and malignant fibrous histiocytoma in one case. The outcomes associated with all malignancies in giant cell tumors were poor, with the worst outcome associated with postradiation SMGCT.

CONCLUSIONS

Malignancies in giant cell tumors of bone always are high-grade sarcomas with a poor prognosis. These lesions must be distinguished from benign giant cell tumors of bone. SMGCT usually is easy to diagnose upon malignant clinicoradiographic presentation. In contrast, PMGCT often mimics giant cell tumors both clinically and radiographically. In addition, upon histologic examination, PMGCT shows areas of conventional giant cell tumor, which can lead to difficulties in making the correct diagnosis.

Vertebral localization of a brown tumor: description of a case and review of the literature

The authors report a case of a female aged 45 years submitted to a long period of hemodialysis, affected with brown tumor of the lumbar spine. Brown tumor must be taken into consideration in the differential diagnosis of osteolytic lesions of the skeleton, particularly in young, nephropathic women undergoing hemodialysis. Brown tumor has a more favorable prognosis as compared to other lesions that have similar clinical and radiographic findings, such as metastatic lesions and giant cell tumors. In the case of brown tumor, in addition to treating lesion of the spine, treatment varying depending on neurological findings and biomechanical complications (structural collapse, segmental kyphosis, pathologic fracture, etc.), removal of the parathyroids and correction of the metabolic alterations is indispensable.

[Primary hyperparathyroidism presenting as a brown tumor of the maxilla and hard palate. Apropos of a case]

Significant controversy persists in the classification of giant cell lesions of the maxillofacial skeleton. Multifocal giant cell lesions are strongly suggestive of hyperparathyroidism brown tumors. Maxillary localization is extremely rare. We report a case of primary hyperparathyroidism manifesting in the form of giant cell tumors of the maxilla, the hard palate and long bones. Biochemistry confirmed the diagnosis. Computed tomography localized the parathyroid tumor at the cervicothoracic junction in the retrosternal area. We discuss the clinical features of skeletal involvement in primary hyperparathyroidism and stress the need for ionized serum calcium assay in case of giant cell tumors of the cranial bones.

Orbital osteoclastoma of apparent extraskeletal origin in a pagetic patient: a case report

A large mass in the right orbit, causing proptosis, ptosis of the right upper eyelid, and limitation to eye movements, was surgically removed from a 51-year-old woman suffering from Paget's bone disease (PBD). Histologically, a giant cell tumor of the bone (osteoclastoma) was diagnosed. No bony involvement was apparent either operatively, microscopically, or on preoperative computed tomographic scans. The neoplasm has not recurred in a 3-year follow-up. In addition to the fact that osteoclastoma complicating PBD is rare, the extraskeletal origin of the tumor is a matter of interest and can be tentatively explained by an unusually powerful systemic stimulus acting on circulating osteoclast precursors. HUM PATHOL 31:1527-1531.

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.

Hyperparathyroid crisis in a patient with a giant brown tumor of the iliac bone: a case report

We observed a patient with a giant brown tumor of the iliac bone due to hyperparathyroidism. There was a risk of pathologic fracture due to huge cysts produced by bone absorption. In hyperparathyroid crisis, control of severe hypercalcemia is difficult without resection of the parathyroid gland.

Extraskeletal osteoclastomas responsive to dexamethasone treatment in Paget bone disease

Giant cell tumors (GCTs) of bone, also called osteoclastomas, complicate Paget bone disease (PBD), though infrequently. Giant cell reparative granulomas (GCRGs), which are histologically similar to GCTs, also occur rarely in pagetic patients. A 45-yr-old black woman with neurofibromatosis, type I, and polyostotic PBD developed slowly-growing masses in the right posterior iliac and left upper parasacral regions. She had multiple cutaneous neurofibromas and café-au-lait spots. Serum alkaline phosphatase activity and urine hydroxyproline levels were elevated. Skeletal radiographs and bone scintigraphy showed changes of widespread PBD. Computerized tomography and magnetic resonance imaging (MRI) delineated masses in the right gluteal and the left lower lumbar paraspinal regions. Five additional smaller masses were found in the abdomen and in the pelvis. Biopsy of the right gluteal mass revealed a GCT. However, we found that this lesion had several histologic features distinct from those of giant cell reparative granulomas or GCT. In our patient's tumor, the huge polykaryons, like osteoclasts, expressed abundant tartrate-resistant acid phosphatase activity, whereas those of GCRG lack this enzyme. Although the polykaryons in conventional GCTs and GCTs in PBD express tartrate-resistant acid phosphatase activity, the location of these tumors in bone differs from the extraskeletal masses encountered in our patient. Furthermore, the larger size of the polykaryons and the greater number of nuclei in our patient's GCT differ from conventional GCTs, but not GCTs in PBD. Her extraskeletal osteoclastoma rapidly shrunk to one third its original size during 2 weeks of oral dexamethasone treatment. Significant clinical improvement lasted about 5 months before additional courses of dexamethasone therapy were necessary. Injections of synthetic salmon calcitonin alone did not affect the tumor's size. Thus, PBD can be complicated by extraskeletal tumors that seem to contain osteoclasts and are responsive to dexamethasone treatment.