Article

Brown tumor of the sternum

Authors:
  • Kaohsiung Chang Gung Memorial Hospital; Chang Gung University
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Abstract

The skeletal changes of severe hyperparathyroidism, known as osteitis fibrosa cystica, are now rarely encountered, because hyperparathyroidism is currently being diagnosed and treated at an early stage. Herein, a case of brown tumor of the sternum is reported; our report adds histologic data on this type of tumor to the literature.

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... A captação do sestamibi em tumor marrom tem sido relatada (14)(15)(16). Este tumor pode localizar-se em diversas estruturas ósseas, inclusive no esterno (21). Uma vez que a presença de glândula paratireóide ectópica no mediastino não é um achado incomum, a captação do sestamibi em tumor marrom no esterno pode ser erroneamente interpretada como a presença de glândula paratireóide aumentada localizada no mediastino, tendo como potencial conseqüência uma exploração cirúrgica desnecessária do tórax. ...
Article
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A cintilografia das paratireóides tem sido utilizada para detectar glândulas patológicas em pacientes com hiperparatireoidismo, tanto antes quanto após a cirurgia de paratireoidectomia. Apesar da elevada especificidade, a cintilografia das paratireóides pode apresentar resultados falso-positivos. Neste artigo, relatamos o caso de uma paciente transplantada renal, com múltiplas lesões osteolíticas na bacia, interpretadas como tumores marrons, que à cintilografia das paratireóides com sestamibi-99mTc apresentou hipercaptação focal do radiofármaco em topografia de porção anterior do mediastino superior. Esta área hipercaptante foi inicialmente interpretada como glândula paratireóide ectópica, porém, após realização de outros exames de imagem e análise mais detalhada, mostrou-se corresponder a tumor marrom em esterno.
... It may mimic giant-cell tumors of bone, which may be confused with malignancies in the absence of appropriate clinical and imaging information. Even though the " brown tumor " can localize anywhere in the skeleton, the preferential locations are the head bones (particularly the mandible), and the ends of long bones and ribs[8,9,10,11,12,13,14]. Obviously, an unusual brown tumor localization may render the differential diagnosis of skeletal osteolytic lesions difficult. ...
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A 63-year-old woman presented to the Orthopedic Unit of our hospital complaining of right hip pain of 6 months' duration associated with a worsening limp. Her past medical history included chronic renal insufficiency. Physical examination revealed deep pain in the iliac region and severe restriction of the right hip's articular function in the maximum degrees of range of motion. X-rays and CT scan detected an osteolytic and expansive lesion of the right supra-acetabular region with structural reabsorption of the right iliac wing. 99mTc-MDP whole-body bone scan showed an abnormal uptake in the right iliac region. Bone biopsy revealed an osteolytic lesion with multinucleated giant cells, indicating a brown tumor. Serum intact PTH was elevated (1020 pg/ml; normal values, 12-62 pg/ml), but her serum calcium was normal (total=9.4 mg/dl, nv 8.5-10.5; ionized=5.0 mg/dl, nv 4.2-5.4) due to the coexistence of chronic renal failure. 99mTc-MIBI scintigraphy revealed a single focus of sestamibi accumulation in the left retrosternal location, which turned out to be an intrathoracic parathyroid adenoma at surgical exploration. After surgical removal of the parathyroid adenoma, PTH levels decreased to 212 pg/ml. Three months after parathyroidectomy, the imaging studies showed complete recovery of the osteolytic lesion, thus avoiding any orthopedic surgery. This case is noteworthy because (1) primary hyperparathyroidism was not suspected due to the normocalcemia, likely attributable to the coexistence of chronic renal failure; and (2) it was associated with a brown tumor of unusual location (right supra-acetabular region).
... A captação do sestamibi em tumor marrom tem sido relatada (14)(15)(16). Este tumor pode localizar-se em diversas estruturas ósseas, inclusive no esterno (21). Uma vez que a presença de glândula paratireóide ectópica no mediastino não é um achado incomum, a captação do sestamibi em tumor marrom no esterno pode ser erroneamente interpretada como a presença de glândula paratireóide aumentada localizada no mediastino, tendo como potencial conseqüência uma exploração cirúrgica desnecessária do tórax. ...
Article
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Parathyroid scintigraphies have been used to detect pathological parathyroid glands either before as well as after the parathyroid resection surgery in patients with hyperparathyroidism. Although this test presents high specificity for detection of increased parathyroid glands, there exist causes of false positive results. In the present article, we report a case of a renal transplanted patient, with multiple lytic lesions on pelvic bones reported as brown tumors, who presented a focal uptake in the anterior portion of the superior mediastinum on Tc-99m sestamibi scintigraphy. This focal uptake, initially thought to be an ectopic parathyroid gland, after a more detailed analysis and the performance of other imaging diagnostic tests was demonstrated to be a brown tumor of the sternum.
Chapter
A 23-year-old girl with hyperparathyroidism was referred for parathyroid scintigraphy in 1986 following a previously failed parathyroidectomy. The patient had raised serum calcium and parathormone. On examination, there was a palpable nodule in the left lobe of the thyroid.
Article
Bone disease associated with primary hyperparathyroidism, known as osteitis fibrosa cystica, is now very rarely encountered, since the parathyroid disorder is most often diagnosed at the early stage of asymptomatic hypercalcemia. Here, we report the case of a patient with multiple pleural-based masses and hypercalcemia, which led to the presumptive diagnosis of malignancy. However, histological and laboratory data were consistent with the development of brown tumors of the ribs due to underlying severe hyperparathyroidism.
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Dual radionuclide imaging using a combination of 201Tl with either 99mTcO4- or 123I is recognized as a useful procedure in the preoperative localization of parathyroid adenomas. Recently, 99mTc-sestamibi (MIBI) has been introduced for myocardial perfusion imaging as an alternative to 201Tl. The purpose of this prospective study was to evaluate parathyroid scan using early and late imaging following MIBI injection. Twenty-three patients (21 F, 2 M, mean age: 57 yr) with a clinical and biologic diagnosis of hyperparathyroidism were submitted to a MIBI study prior to surgical exploration of the neck. Cervico-thoracic planar imaging (anterior view, 10 min/view) was performed at 15 min and at 2-3 hr after an intravenous injection of 20-25 mCi of MIBI. A positive MIBI scan for parathyroid adenoma was defined as an area of increased focal uptake which persisted on late imaging, contrary to the uptake in the normal thyroid tissue which progressively decreases over time (differential washout). Surgical exploration of the neck, performed between 1 day and 72 days (average: 16 days) after the MIBI study, showed a parathyroid adenoma in 21 patients and hyperplasia in two patients. MIBI scan correctly detected and localized 19/21 adenomas (90%). In conclusion, parathyroid imaging using a single radionuclide with MIBI (early and late study with differential washout analysis) is a promising procedure in the preoperative detection and localization of parathyroid adenomas in patients with primary hyperparathyroidism.
Article
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The sustained effects of biochemical screening to increase both apparent incidence and age at diagnosis indicate that, without screening, most patients with primary hyperparathyroidism would would never be diagnosed. This suggests that asymptomatic patients discovered as a result of screening have a nonprogressive form of the disease, with adverse health effects that are few or nontraditional, for which treatment policies validated only in symptomatic patients may be inappropriate. Accordingly, in 1975 we formulated criteria for withholding surgical treatment from such patients. Of 174 who were eligible for study over a 10 year period, clinical, biochemical, and densitometric assessment was repeated after at least 1 year (mean 52 months) in 106 patients who did not differ in any initial characteristic from 68 patients in whom follow-up was inadequate. There was no change in symptoms, no disease complications, and no change in any index of hormone secretion or disease severity. In 30 patients, individual regression slopes against time were not significant for any serum measurement. In these patients the disease appeared to have stopped progressing by the time the diagnosis was made, most likely because of cessation of tumor growth. There was a significant deficit in appendicular cortical bone at the time of diagnosis but no further acceleration of bone loss thereafter. In an earlier study, surgical cure was followed by a modest increase in forearm bone density for the first 6 months, but even after 3 years only about 20% of the deficit was corrected. The deficit in bone density is smaller in the spine than in the forearm and is not accompanied by any increase in vertebral fracture risk.(ABSTRACT TRUNCATED AT 250 WORDS)
Article
The classic bone disease of primary hyperparathyroidism, osteitis fibrosa cystica, was characterized by subperiosteal bone resorption, osteopenia, and "brown tumors." Since the description of this skeletal disorder, the clinical profile of primary hyperparathyroidism has evolved markedly. The disease today is often characterized by no more than asymptomatic hypercalcemia, and severe bone disease is a distinct rarity. However, as we have endeavored to show in this article, newer and more sensitive techniques show significant evidence of the effect of excess parathyroid hormone on the skeleton. Bone density as measured by photon absorptiometry and bone histomorphometry show a deficit of cortical bone and a preservation or increase in cancellous bone elements in mild primary hyperparathyroidism with no clinical evidence of skeletal disease. Important questions exist as to the therapeutic implications of these data. Does the presence of parathyroid hormone effect on sophisticated testing portend the development of clinical bone disease? Should these data be used as a rationale for surgical intervention in patients who might otherwise be followed conservatively with mild primary hyperparathyroidism? The answers to these questions must await further data collection and study.
Article
Primary hyperparathyroidism is generally treated by primary neck exploration. Particularly in patients with hyperparathyroidism caused by adenoma, cervical exploration is generally curative, and extensive preoperative localization studies are unnecessary. If, after thorough primary cervical exploration, no adenoma is identified or at least four parathyroid glands are not confirmed and the patient's hypercalcemia persists, radiologic localization studies are indicated prior to a repeat operation. Persistent hypercalcemia in defined as the failure of calcium levels to return to normal soon after parathyroid exploration; recurrent hyperparathyroidism is defined as hypercalcemia that follows 6 months of low or normal serum calcium levels. Persistent or recurrent hypercalcemia not controlled by a primary cervical exploration may be due to an ectopic parathyroid adenoma, either outside the usual anatomic sites in the neck or in the mediastinum. Techniques used for localization of these ectopic adenomas include sonography, computed tomography scanning, venous sampling, digital angiography, and selective arteriography. Of these techniques, selective arteriography not only has been precise but also offers the possibility of therapy. A small group of patients who underwent embolization of ectopic parathyroid adenomas through the angiographic catheter was reviewed 6 years ago with the cautious suggestion that this technique, under highly specialized indications, might offer a percutaneous treatment of hyperparathyroidism in selected patients. Since the time of the preliminary report, radiologic techniques have been modified, indications for patient selection have been refined, and experience with this method of managing persistent hyperparathyroidism has increased. It is the purpose of this report to summarize this experience with long-term follow-up of those patients treated by transcatheter staining.
Article
ONE HUNDRED years ago, the Swedish medical student Ivan Sandström (1) discovered the parathyroid glands in dogs and described their existence in man, horses, oxen, rabbits, and cats. He never realized the significance of his discovery or the important function of this organ in the control of calcium metabolism. For a long time the function of this organ remained unidentified, and tetany after thyroid surgery was considered the result of the absence of the thyroid. Not until it was discovered that the parathyroid glands were closely linked to tetany did they begin to receive attention. Gley (2) observed that 14 of 16 rabbits died of tetany if, together with the thyroid gland, two other glands lying underneath it were removed. Subsequent attempts to repeat these experiments failed because nothing was known about the internal and external arrangements of these glands. Not until Kohn (3) described these internal glands as existing in a great variety of animals did the basis exist for the experiments of two Italian researchers, Vassale and Generali (4). They found that removal of the parathyroid glands with retention of the thyroid gland caused tetany in animals; removal of the thyroid gland with retention of the parathyroid glands caused myxedema and cachexia. These results were confirmed in independent experiments by Waldbaum (5), Pineles (6), Hagenbach (7), Pfeiffer and Mayer (8), and Iselin (9).
The transplantation of parathyroid tissue in man.
  • Niederle B
  • Roka R
  • Brennan M.F
The transplantation of parathyroid tissue in man
  • Niederle