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CASE REPORT
Year : 2016  |  Volume : 15  |  Issue : 1  |  Page : 56-58

Multiple brown tumors caused by a parathyroid adenoma mimicking metastatic bone disease from giant cell tumor


1 Department of Nuclear Medicine and PET, Postgraduate Institute of Medical Education and Research, Chandigarh, Haryana and Punjab, India
2 Department of Orthopedics, Postgraduate Institute of Medical Education and Research, Chandigarh, Haryana and Punjab, India
3 Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, Haryana and Punjab, India

Date of Web Publication18-Dec-2015

Correspondence Address:
Bhagwant Rai Mittal
Department of Nuclear Medicine and PET, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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DOI: 10.4103/1450-1147.167598

PMID: 26912981

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   Abstract 

Brown tumor affects multiple bones in the body with variable clinical symptoms, which may be misdiagnosed as multiple bone metastases or primary bone tumor. In the present case report, we report the usefulness of 99mTc-MDP bone scan and 99mTc-MIBI whole body scan in differentiating brown tumor of hyperparathyroidism from giant cell tumor.

Keywords: Bone scan, brown tumor, giant cell tumor, 99mTc MIBI scan, primary hyperparathyroidism


How to cite this article:
Phulsunga RK, Parghane RV, Kanojia RK, Gochhait D, Sood A, Bhattacharya A, Mittal BR. Multiple brown tumors caused by a parathyroid adenoma mimicking metastatic bone disease from giant cell tumor. World J Nucl Med 2016;15:56-8

How to cite this URL:
Phulsunga RK, Parghane RV, Kanojia RK, Gochhait D, Sood A, Bhattacharya A, Mittal BR. Multiple brown tumors caused by a parathyroid adenoma mimicking metastatic bone disease from giant cell tumor. World J Nucl Med [serial online] 2016 [cited 2019 Dec 15];15:56-8. Available from: http://www.wjnm.org/text.asp?2016/15/1/56/167598


   Introduction Top


Brown tumors are not true tumors and arise in the settings of excess osteoclast activity caused by excretion of parathyroid hormone in association with hyperparathyroidism. Brown tumor affects multiple bones in the body with variable clinical symptoms, which may be misdiagnosed as multiple bone metastases or primary bone tumor. Microscopically, giant cell tumor (GCT) and brown tumor of hyperparathyroidism (BTH) have a similar finding containing giant cells and spindle-shaped cells in fibrous matrix but treatment-wise, both these conditions are totally different.


   Case Report Top


A 42-year-old female patient presented with history of bone pain in the upper region of the left tibia. Magnetic resonance imaging (MRI) showed an expansile lesion in the metadiaphyseal region of the upper one-third region of the left tibia. A biopsy from tibial lesion showed large osteoclastic giant cells in a background of spindle-shaped cells and mononuclear cells. A diagnosis of giant cell tumor (GCT) was made and the patient was treated with curettage and bone grafting followed by local radiotherapy. Subsequently, bone scan was done for metastatic workup of the GCT. (a) 99mTc-methoxyisobutylisonitrile (MIBI) bone scan [Figure 1]a showed multiple foci of increased uptake in the skull bones, mandible, and axial and appendicular skeleton with focally increased uptake in the upper and lower ends of both femurs, both tibia, both shoulder joints and forearm bones. The bone scan findings were more consistent with metabolic bone disease than with metastatic bone disease. Biochemical tests were obtained and the values (serum calcium-15.09 mg/dL, serum phosphorus-2.38 mg/dL, ALP-943.24U/L and iPTH-1987 pg/mL) were in favor of metabolic bone disease. The patient was subjected to 99mTc-MIBI dual-phase (DP) parathyroid scan and whole body scan (WBS). (b) 99mTc-MIBI WBS [Figure 1]b showed increased uptake in the mandible, upper and lower ends of the right femur, both tibial bones and around the shoulder joints, similar to the bone scan and single photon emission computed tomography/computed tomography (SPECT/CT) of lower limb [Figure 1]c showed MIBI avid lytic-cystic lesions in the lower end of the right femur and mid shaft of both tibial bones.
Figure 1: Tc99m methylene diphosphonate bone scan (a) showing multiple foci of increased uptake in the skull bones, mandible, axial and appendicular skeleton with focally increased uptake in the upper and lower ends of both femurs, both tibia, both shoulder joints and forearm bones. 99mTc-MIBI WBS (b) showing increased uptake in the mandible, upper and lower ends of the right femur, both tibial bones, and around the shoulder joints, similar to that of the bone scan and SPECT/CT (c) of the lower limb that showed MIBI avid lytic-cystic lesions in the lower end of the right femur and midshaft of both tibial bones

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DP 99mTc-MIBI parathyroid scan of the neck [Figure 2]a showed focally increased tracer uptake in relation to the inferior pole of the right lobe of thyroid gland, which on SPECT/CT [Figure 2]b of the neck was localized to an isodense lesion of 1.3 × 1.2 cm size inferior to lower pole of the right lobe of thyroid gland suggestive of right inferior parathyroid adenoma, which later on was confirmed on histopathology [Figure 2]c. The patient underwent surgery and histopathology that showed chief cells, clear cells and tumor cell with thick capsule (hematoxylin and eosin stain, 400x magnification) confirming diagnosis of parathyroid adenoma. 99mTc-MIBI WBS [Figure 3]a and [Figure 3]b acquired 2 months after surgical removal of parathyroid adenoma ([Figure 3]a and [Figure 3]b) showed complete resolution of MIBI avid lesions as compared to presurgical scan and DP parathyroid scan [Figure 3]c showed no abnormal MIBI avid lesion in the neck. The clinical symptom and laboratory results of the patient also improved.
Figure 2: DP 99mTc-MIBI parathyroid scan of the neck (a) showing focally increased tracer uptake in relation to the inferior pole of the right lobe of thyroid gland, which on SPECT/CT of the neck (b) localized to an isodense lesion inferior to lower pole of the right lobe of thyroid gland, suggestive of right inferior parathyroid adenoma that was confirmed on histopathology (c)

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Figure 3: 99mTc-MIBI WBS scan acquired 2 months after surgical removal of parathyroid adenoma (a and b) shows complete resolution of MIBI avid lesions as compared to presurgical scan and DP parathyroid scan (c) showing no abnormal MIBI avid lesion in the neck

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Brown tumor contains giant cells, spindle-shaped cells and a background of fibrous matrix. Microscopically, BTH, giant-cell granuloma,[1] and GCT [2] have similar findings because all these conditions contain giant-cell lesions. Differential diagnoses of all these conditions may not be possible without knowledge of the clinical features, radiological findings, and laboratory results. Brown tumor commonly affects the jaws, skull, pelvis, clavicle, ribs, femurs and spine.[2],[3],[4],[5] The CT scan findings are not specific for brown tumor [2] and show multilobular cystic change.[6],[7] Multiple bony lesions of brown tumor may be misdiagnosed on CT scan as metastatic carcinoma, bone cysts, and especially GCT.[8] 99mTc-MDP bone scan is an effective method for distinguishing BTH from multiple bone metastases.[9]


   Conclusion Top


In conclusion, diagnosis of BTH must be considered in patients with multiple bone lesions, elevated calcium and alkaline phosphatase (ALP), and mimicking multiple bone metastases especially from GCT, as these conditions have similar histopathological and radiological findings.[10],[11],[12] The 99mTc-MDP bone scan and 99mTc-MIBI WBS are useful in differentiating and managing these conditions.

 
   References Top

1.
Kocher MS, Gebhardt MC, Jaramillo D, Perez-Atayde AR. Multiple lytic skeletal lesions and hypercalcemia in a 13-year-old girl. Clin Orthop Relat Res 2000;374:298-302, 317-9.  Back to cited text no. 1
    
2.
Takeshita T, Tanaka H, Harasawa A, Kaminaga T, Imamura T, Furui S. Brown tumor of the sphenoid sinus in patient with secondary hyperparathyroidism: CT and MR imaging findings. Radiat Med 2004;22:265-8.  Back to cited text no. 2
    
3.
Kanaan I, Ahmed M, Rifai A, Alwatban J. Sphenoid sinus brown tumor of secondary hyperparathyroidism: Case report. Neurosurgery 1998;42:1374-7.  Back to cited text no. 3
    
4.
Keyser JS, Postma GN. Brown tumor of the mandible. Am J Otolaryngol 1996;17:407-10.  Back to cited text no. 4
    
5.
Fasanelli S, Graziani M, Boldrini R, Bosman C. “Brown tumor” of the maxilla. Pediatr Radiol 1992;22:142-4.  Back to cited text no. 5
    
6.
Smith J, Huvos AG, Chapman M, Rabbs C, Spiro RH. Hyperparathyroidism associated with sarcoma of bone. Skeletal Radiol 1997;26:107-12.  Back to cited text no. 6
    
7.
Erem C, Hscihasanoglu A, Cinel A, Ersöz HO, Reis A, Sari A, et al. Sphenoid sinus brown tumor, a mass lesion of occipital bone and hypercalcemia: An unusual presentation of primary hyperparathyroidism. J Endocrinol Invest 2004;27:366-9.  Back to cited text no. 7
    
8.
Scholl RJ, Kellett HM, Neumann DP, Lurie AG. Cysts and cystic lesions of the mandible: Clinical and radiologic-histopathologic review. Radiographics 1991;19:1107-24.  Back to cited text no. 8
    
9.
Jordan KG, Telepak RJ, Spaeth J. Detection of hypervascular brown tumors on three-phase bone scan. J Nucl Med 1993;34:2188-90.  Back to cited text no. 9
    
10.
Joyce JM, Idea RJ, Grossman SJ, Liss RG, Lyons JB. Multiple brown tumors in unsuspected primary hyperparathyroidism mimicking metastatic disease on radiograph and bone scan. Clin Nucl Med 1994;19:630-5.  Back to cited text no. 10
    
11.
Hsieh MC, Ko JY, Eng HL. Pathologic Fracture of the distal femur in osteitis fibrosa cystica simulating metastatic disease. Arch Orthop Trauma Surg 2004;124:498-501.  Back to cited text no. 11
    
12.
Pai M, Park CH, Kim BS, Chung YS, Park HB. Multiple brown tumors in parathyroid carcinoma mimicking metastatic bone disease. Clin Nucl Med 1997;22:691-4.  Back to cited text no. 12
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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