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Sun L, Peng R. The value of integration of bone scan and targeted SPECT/CT in diagnosis of primary hyperparathyroidism with multiple bone brown tumor. Skeletal Radiol 2023; 52:2505-2511. [PMID: 37227482 DOI: 10.1007/s00256-023-04361-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 04/13/2023] [Accepted: 05/03/2023] [Indexed: 05/26/2023]
Abstract
Although parathyroid bone disease is rarely seen nowadays, skeletal manifestation can be the first sign of hyperparathyroidism (HPT) in some clinical practice. Nevertheless, the diagnosis of HPT is often overlooked. We describe three cases of multiple brown tumors (BT) in which bone pain and destruction were the first symptoms that masqueraded as a malignancy. However, according to the results of bone scan and targeted single-photon emission computed tomography/computed tomography (SPECT/CT), we considered BTs as the diagnosis in all of three cases. The final diagnoses were confirmed by laboratory tests and post-parathyroidectomy pathology. Parathyroid hormone (PTH) is significantly elevated in primary hyperparathyroidism (PHPT) as we know. However, such elevation is virtually never seen in malignancies. Diffuse or multiple foci of tracer uptakes in the bone scan were always seen in bone metastasis, multiple myeloma, and other bone neoplasm. When patients visited nuclear medicine for first consultation without biochemical results, radiological evidence from planar bone scan and targeted SPECT/CT can help in distinguishing the skeletal diseases. Lytic bone lesions with sclerosis, intra-focal or ectopic ossification and calcification, fluid-fluid level, and distribution of the lesions may be helpful in the differential diagnosis in these reported cases. In conclusion, when patients present with multiple foci of uptake on bone scan, targeted SPECT/CT is acquired for suspicious lesions, which can increase the diagnostic sensitivity and reduce unnecessary interventions and treatment. Moreover, BTs should be always kept in differential diagnosis of multiple lesions without a conclusive primary tumor.
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Affiliation(s)
- Lixin Sun
- Department of Nuclear Medicine, Beijing Luhe Hospital, Capital Medical University, Xinhua Road 82, Tong Zhou District, Beijing, 101149, China
| | - Ruchen Peng
- Department of Radiology, Beijing Luhe Hospital, Capital Medical University, Xinhua Road 82, Tong Zhou District, Beijing, 101149, China.
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Miwa S, Tanaka T, Aiba H, Yamada S, Otsuka T, Tsuchiya H. Multiple Bone Cysts Caused by Hyperparathyroidism: A Case Report and Review of the Literature. CANCER DIAGNOSIS & PROGNOSIS 2023; 3:590-596. [PMID: 37671306 PMCID: PMC10475927 DOI: 10.21873/cdp.10259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 07/13/2023] [Indexed: 09/07/2023]
Abstract
Background Brown tumor, a skeletal complication of severe hyperparathyroidism, comprises reparative granulation tissue and proliferating fibrous tissue with hemosiderin deposition. Multiple brown tumors are extremely rare complications of primary hyperparathyroidism. Case Report A 41-year-old woman presented with pain in the left knee. Radiography showed multiple cystic lesions in both femurs and the left proximal tibia, and additional radiography showed multiple cystic lesions in the left humerus and ulna. Magnetic resonance imaging (MRI) revealed multiple cystic lesions in the bilateral femurs, left proximal tibia, and ilium. Laboratory tests revealed hypercalcemia (albumin-corrected calcium level, 13.9 mg/dl), hypophosphatemia (phosphate level, 1.6 mg/dl), elevated level of alkaline phosphatase level (614 U/l), and markedly elevated parathyroid hormone (PTH) level (1,070 pg/ml; normal range=10-65 ng/l). 99mTc-hexakis-2-methoxyisobutyl-isonitrile scintigraphy revealed tracer accumulation in the left upper parathyroid gland, which was consistent with parathyroid tumor. Although resection of the parathyroid tumor was planned, the patient developed parathyroid apoplexy before tumor excision. After the parathyroid apoplexy, serum calcium and PTH levels temporarily normalized. Resurgence of the PTH level was observed 2 years after the diagnosis, and the patient underwent left upper parathyroidectomy. One year after the tumor excision, the patient had no symptoms, and MRI showed shrinkage of the cystic bone lesions. Conclusion This report emphasizes the importance of considering hyperparathy-roidism as a differential diagnosis for patients with multiple bone lesions.
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Affiliation(s)
- Shinji Miwa
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Tomohiro Tanaka
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Hisaki Aiba
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Satoshi Yamada
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Takanobu Otsuka
- Department of Orthopaedic Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
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3
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Jacquet-Francillon N, Prevot N. Brown tumors in nuclear medicine: a systematic review. Ann Nucl Med 2023; 37:255-270. [PMID: 36933117 DOI: 10.1007/s12149-023-01832-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 02/27/2023] [Indexed: 03/19/2023]
Abstract
Brown tumors (BT) are abnormal bone-repair processes and a consequence of hyperparathyroidism. The diagnosis of these lytic lesions in nuclear medicine, while a challenge, is not so rare, because functional imaging is used both in the management of cancer and hyperparathyroidism. The main objective of this review is to summarize the knowledge and the evidence concerning BT and the different imaging modalities in nuclear medicine. A systematic review was performed in Embase, PubMed and Google Scholar from 2005 to 2022. We included articles describing BT in the following imaging modalities: [18F]-fluorodeoxyglucose PET/CT, [18F]-fluorocholine or [11C]-fluorocholine PET/CT, [99mTc]-Sestamibi scintigraphy, bone scan, [18F]-sodium fluoride PET/CT, [68Ga]-FAPI PET/CT; [68Ga]-DOTATATE PET/CT; [11C]-methionine PET/CT. For each modality, appearance, avidity for radiotracer, available quantitative parameters and imaging evolution after parathyroidectomy were collected and analyzed. Fifty-two articles were included for a total of 392 BT lesions. If the diagnosis of BT is evoked on a known lesion, performing a [18F]-fluorocholine PET/CT imaging seems the most appropriate. In [18F]-fluorodeoxyglucose, [18F]-fluorocholine, [18F]-sodium fluoride PET/CT and bone scan, BT can mimic metastatic disease. BT uptakes appear reversible after parathyroidectomy, with a more or less rapid decrease depending on the imaging modality used.
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Affiliation(s)
- Nicolas Jacquet-Francillon
- Nuclear Medicine Department, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Hopital Lyon Sud, 165 Chemin du Grand Revoyet, 69495, Pierre-Bénite, France.
| | - Nathalie Prevot
- Department of Nuclear Medicine, University Hospital of Saint-Etienne, Saint-Étienne, France.,Univ Jean Monnet, INSERM, U 1059 Sainbiose, 42023, Saint-Étienne, France
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Petranović Ovčariček P, Giovanella L, Carrió Gasset I, Hindié E, Huellner MW, Luster M, Piccardo A, Weber T, Talbot JN, Verburg FA. The EANM practice guidelines for parathyroid imaging. Eur J Nucl Med Mol Imaging 2021; 48:2801-2822. [PMID: 33839893 PMCID: PMC8263421 DOI: 10.1007/s00259-021-05334-y] [Citation(s) in RCA: 102] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/23/2021] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Nuclear medicine parathyroid imaging is important in the identification of hyperfunctioning parathyroid glands in primary hyperparathyroidism (pHPT), but it may be also valuable before surgical treatment in secondary hyperparathyroidism (sHPT). Parathyroid radionuclide imaging with scintigraphy or positron emission tomography (PET) is a highly sensitive procedure for the assessment of the presence and number of hyperfunctioning parathyroid glands, located either at typical sites or ectopically. The treatment of pHPT is mostly directed toward minimally invasive parathyroidectomy, especially in cases with a single adenoma. In experienced hands, successful surgery depends mainly on the exact preoperative localization of one or more hyperfunctioning parathyroid adenomas. Failure to preoperatively identify the hyperfunctioning parathyroid gland challenges minimally invasive parathyroidectomy and might require bilateral open neck exploration. METHODS Over a decade has now passed since the European Association of Nuclear Medicine (EANM) issued the first edition of the guideline on parathyroid imaging, and a number of new insights and techniques have been developed since. The aim of the present document is to provide state-of-the-art guidelines for nuclear medicine physicians performing parathyroid scintigraphy, single-photon emission computed tomography/computed tomography (SPECT/CT), positron emission tomography/computed tomography (PET/CT), and positron emission tomography/magnetic resonance imaging (PET/MRI) in patients with pHPT, as well as in those with sHPT. CONCLUSION These guidelines are written and authorized by the EANM to promote optimal parathyroid imaging. They will assist nuclear medicine physicians in the detection and correct localization of hyperfunctioning parathyroid lesions.
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Affiliation(s)
- Petra Petranović Ovčariček
- EANM Thyroid Committee, Vienna, Austria
- Department of Oncology and Nuclear medicine, University Hospital Center "Sestre milosrdnice", Zagreb, Croatia
| | - Luca Giovanella
- EANM Thyroid Committee, Vienna, Austria
- Clinic for Nuclear Medicine and Competence Centre for Thyroid Diseases, Imaging Institute of Southern Switzerland, Bellinzona, Switzerland
- Clinic for Nuclear Medicine and Interdisciplinary Thyroid Centre, University Hospital and University of Zurich, Zurich, Switzerland
| | - Ignasi Carrió Gasset
- Department of Nuclear Medicine, Hospital Sant Pau and Autonomous University of Barcelona, Barcelona, Spain
| | - Elif Hindié
- Department of Nuclear Medicine, Bordeaux Hospital and University, Bordeaux, France
| | - Martin W Huellner
- Department of Nuclear Medicine, University Hospital and University of Zurich, Zurich, Switzerland
| | - Markus Luster
- EANM Thyroid Committee, Vienna, Austria
- Department of Nuclear Medicine, University Hospital Marburg, Marburg, Germany
| | - Arnoldo Piccardo
- Department of Nuclear Medicine, E.O. Ospedali Galliera, Genoa, Italy
| | - Theresia Weber
- Department of Endocrine Surgery, Katholisches Klinikum Mainz, Mainz, Germany
| | - Jean-Noël Talbot
- Nuclear Medicine, Hospital Tenon APHP and Sorbonne University, Paris, France
| | - Frederik Anton Verburg
- EANM Thyroid Committee, Vienna, Austria.
- Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands.
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Holzgreve A, Fabritius MP, Knösel T, Mittlmeier LM, Rübenthaler J, Tiling R, Auernhammer CJ, Bartenstein P, Unterrainer M. Molecular Imaging with 18F-FDG PET/CT and 99mTc-MIBI SPECT/CT in Osteitis Fibrosa Cystica Generalisata. Diagnostics (Basel) 2021; 11:diagnostics11081355. [PMID: 34441290 PMCID: PMC8393991 DOI: 10.3390/diagnostics11081355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 07/23/2021] [Accepted: 07/27/2021] [Indexed: 11/27/2022] Open
Abstract
Benign so-called “brown tumors” secondary to hyperparathyroidism are a rare diagnostic pitfall due to their impressively malignant-like character in various imaging modalities. We present the case of a 65-year-old male patient with multiple unclear osteolytic lesions on prior imaging suspicious for metastatic malignant disease. Eventually, findings of 18F-FDG PET/CT staging and 99mTc-MIBI scintigraphy resulted in revision of the initially suspected malignant diagnosis. This case illustrates how molecular imaging findings non-invasively corroborate the correct diagnosis of osteitis fibrosa cystica generalisata with the formation of multiple benign brown tumors.
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Affiliation(s)
- Adrien Holzgreve
- Department of Nuclear Medicine, University Hospital, LMU Munich, 81377 Munich, Germany; (L.M.M.); (R.T.); (P.B.)
- Correspondence: ; Tel.: +49-89-4400-74646
| | - Matthias P. Fabritius
- Department of Radiology, University Hospital, LMU Munich, 81377 Munich, Germany; (M.P.F.); (J.R.); (M.U.)
| | - Thomas Knösel
- Institute of Pathology, Faculty of Medicine, LMU Munich, 81377 Munich, Germany;
| | - Lena M. Mittlmeier
- Department of Nuclear Medicine, University Hospital, LMU Munich, 81377 Munich, Germany; (L.M.M.); (R.T.); (P.B.)
| | - Johannes Rübenthaler
- Department of Radiology, University Hospital, LMU Munich, 81377 Munich, Germany; (M.P.F.); (J.R.); (M.U.)
| | - Reinhold Tiling
- Department of Nuclear Medicine, University Hospital, LMU Munich, 81377 Munich, Germany; (L.M.M.); (R.T.); (P.B.)
| | | | - Peter Bartenstein
- Department of Nuclear Medicine, University Hospital, LMU Munich, 81377 Munich, Germany; (L.M.M.); (R.T.); (P.B.)
| | - Marcus Unterrainer
- Department of Radiology, University Hospital, LMU Munich, 81377 Munich, Germany; (M.P.F.); (J.R.); (M.U.)
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Abstract
Osteitis fibrosa cystica is a rare presentation of both primary and secondary hyperparathyroidism. In this perspective, we provide a historical backdrop to this form of parathyroid disease and contend that this clinical presentation of excess parathyroid hormone, particularly in primary hyperparathyroidism, is still seen today. In view of its rarity and the way it typically presents, the diagnosis of metastatic cancer is often the first diagnostic impression. © 2020 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Waldemar Misiorowski
- Endocrinology Department, Centre of Postgraduate Medical Education Bielanski Hospital Warsaw Poland
| | - John P Bilezikian
- Department of Medicine, Endocrinology Division, College of Physicians and Surgeons Columbia University New York 10032 NY USA
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7
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Gochhait D, Govindarajalou R, Kar R, Rangarajan V, Dehuri P, Dubashi B. Plasmacytoma of thyroid clinically and morphologically mimicking primary thyroid carcinoma. Cytopathology 2018; 30:113-116. [PMID: 30462353 DOI: 10.1111/cyt.12658] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Accepted: 11/11/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Debasis Gochhait
- Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Ramkumar Govindarajalou
- Department of Radiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Rakhee Kar
- Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Vidhyalakshmi Rangarajan
- Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Priyadarshini Dehuri
- Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Biswajit Dubashi
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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8
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Broehm CJ, Inwards CY, Al-Ibraheemi A, Wenger DE, Jenkins SM, Jin L, Oliveira AM, Zreik RT, Carter JM, Boland JM, Fritchie KJ. Giant Cell Tumor of Bone in Patients 55 Years and Older: A Study of 34 Patients. Am J Clin Pathol 2018; 149:222-233. [PMID: 29425276 DOI: 10.1093/ajcp/aqx155] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Most giant cell tumors of bone (GCTs) occur in patients aged 20 to 40 years. We analyzed features of GCT in patients 55 years or older. METHODS GCTs were examined for fibrosis, matrix, cystic change, histiocytes, mitoses, and necrosis. Clinical/radiologic data were collected. RESULTS Thirty-four (5%) of 710 GCTs occurred in patients older than 55 years (14/20 male/female; 56-83 years) in long bones (n = 24), vertebrae (n = 6), pelvis (n = 3), and metacarpal (n = 1). Imaging was classic in 26 of 27 cases; one case appeared malignant. Morphologic patterns included fibrosis (n = 29), bone formation (n = 19), cystic change (n = 8), necrosis (n = 8), foamy histiocytes (n = 7), and secondary aneurysmal bone cyst formation (n = 1). Mitoses ranged from 0 to 18 per 10 high-power fields. Six recurred; one patient developed metastasis. Four of five cases harbored H3F3A mutations. CONCLUSIONS GCTs in patients 55 years or older share pathologic characteristics with those arising in younger adults. Fibrosis and reactive bone are common, potentially leading to diagnostic confusion in this population. No histologic features correlate with adverse outcome.
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Affiliation(s)
- Cory J Broehm
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Carrie Y Inwards
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Alyaa Al-Ibraheemi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - Sarah M Jenkins
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Long Jin
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Andre M Oliveira
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Riyam T Zreik
- Department of Pathology, Baylor Scott & White Health, Temple, TX
| | - Jodi M Carter
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Jennifer M Boland
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Karen J Fritchie
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
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Misiorowski W, Czajka-Oraniec I, Kochman M, Zgliczyński W, Bilezikian JP. Osteitis fibrosa cystica-a forgotten radiological feature of primary hyperparathyroidism. Endocrine 2017; 58:380-385. [PMID: 28900835 PMCID: PMC5671544 DOI: 10.1007/s12020-017-1414-2] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 08/08/2017] [Indexed: 12/27/2022]
Abstract
UNLABELLED Although bone disease and stone disease are the universally accepted classical manifestations of primary hyperparathyroidism, clinical parathyroid bone disease is rarely seen today in the United States (<5% of patients) and Western Europe. Nevertheless, in a given patient, classical skeletal involvement can be the first sign of primary hyperparathyroidism, but not recognized because it is not usually included, anymore, in the differential diagnosis of this manifestation of skeletal disease. We describe four cases of primary hyperparathyroidism in which the first clinical manifestation of the disease was a pathological fracture that masqueraded as a malignancy. The presence of large osteolytic lesions gave rise to the initial diagnosis of a primary or metastatic cancer. In none of the reported cases was primary hyperparathyroidism with osteitis fibrosa considered as the diagnosis. It would seem to us that this course is best explained by the fact that in many countries such manifestations of primary hyperparathyroidism have become a rarity. In fact, the incidence of osteitis fibrosa among patients with primary hyperparathyroidism in the US is estimated as so rare, that in majority of medical centers routine x-ray examinations of the bones in these patients is not recommended. The X-ray or computed tomography scan findings of osteitis fibrosa cystica include lytic or multilobular cystic changes. Multiple bony lesions representing brown tumors may be misdiagnosed on computed tomography scan as metastatic carcinoma, bone cysts, osteosarcoma, and especially giant-cell tumor. Distinguishing between primary hyperparathyroidism and malignancy is made readily by the concomitant measurement of parathyroid hormone which in primary hyperparathyroidism, again, will be markedly elevated. In the hypercalcemias of malignancy, such elevations of parathyroid hormone are virtually never seen. CONCLUSION When radiographic evidence of a lytic lesion and hypercalcemia are present, primary hyperparathyroidism should always be considered in the differential diagnosis.
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Affiliation(s)
- Waldemar Misiorowski
- Endocrinology Dept, Medical Center for Postgraduate Education, Bielanski Hosp., Ceglowska 80 str., 01-809, Warsaw, Poland.
| | - Izabela Czajka-Oraniec
- Endocrinology Dept, Medical Center for Postgraduate Education, Bielanski Hosp., Ceglowska 80 str., 01-809, Warsaw, Poland
| | - Magdalena Kochman
- Endocrinology Dept, Medical Center for Postgraduate Education, Bielanski Hosp., Ceglowska 80 str., 01-809, Warsaw, Poland
| | - Wojciech Zgliczyński
- Endocrinology Dept, Medical Center for Postgraduate Education, Bielanski Hosp., Ceglowska 80 str., 01-809, Warsaw, Poland
| | - John P Bilezikian
- Department of Medicine, Endocrinology Division, College of Physicians and Surgeons, Columbia University, New York, NY, USA
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10
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Histologic Spectrum of Giant Cell Tumor (GCT) of Bone in Patients 18 Years of Age and Below: A Study of 63 Patients. Am J Surg Pathol 2017; 40:1702-1712. [PMID: 27526293 DOI: 10.1097/pas.0000000000000715] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Although the majority of giant cell tumors (GCTs) of the bone occur in adult patients, occasionally they arise in the pediatric population. In this setting they may be mistaken for tumors more commonly seen in this age group, including osteosarcoma, aneurysmal bone cyst, and chondroblastoma. All cases of primary GCT of the bone arising in patients 18 years and below were retrieved from our institutional archives and examined with emphasis on the evaluation of various morphologic patterns. Clinical/radiologic records were reviewed when available. Analysis for H3F3A/H3F3B mutations was performed in a subset of cases. Sixty-three (of 710) patients treated at our institution for GCT were 18 years of age and below. The following morphologic patterns were identified: fibrosis (31 cases, 49%), reactive-appearing bone (26, 41%), cystic change (7, 11%), foamy histiocytes (6, 10%), secondary aneurysmal bone cyst (3, 5%), and cartilage (2, 3%). Infarct-like necrosis was present in 17 tumors (27%), and the mitotic rate ranged from 0 to 35 mitoses/10 high-power fields (median 5 mitoses/10 high-power field). Follow-up information (n=55; 6 mo to 69.6 y; median, 11.6 y) showed 21 patients with local recurrence (38%) and 2 patients with lung metastasis (4%). Polymerase chain reaction with sequencing showed that 5 of 5 tested cases harbored H3F3A mutations. In summary, GCT arising in the pediatric population is rare, representing 9% of GCTs seen at our institution. The morphologic spectrum of these tumors is broad and similar to that seen in patients above 18 years of age. It is important to recognize that matrix formation may be observed in GCT, including reactive-appearing bone and cartilage, as well as areas of fibrosis mimicking osteoid production, to avoid misclassification as osteosarcoma or other giant cell-rich lesions common in children.
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