Vignette hyperparathyroidism: glimpse into its history

Brown Tumors of the Jaws: A Retrospective Study

Objectives

(1) Describe the clinical spectrum, imaging features, management, and outcome of brown tumors (BT) of the jaws. (2) Determine via a literature review the facts and controversies around the characteristics and management of this lesion.

Materials and methods

Our study was approved by the institutional committee of Sahloul University Hospital in accordance with the ethical standards of the Declaration of Helsinki. Sixteen patients with BT in the context of a primary, secondary, and tertiary hyperparathyroidism were treated and followed up during their recovery.

Results

This study reports 16 patients with a mean age of 48 years old. Brown tumor lesions were associated with primary hyperparathyroidism in 6 cases (38%), secondary hyperparathyroidism to chronic kidney failure in 5 cases (31%), and tertiary hyperparathyroidism in the context of a long lasting CRI in 5 cases. Their location was maxillary in 7 cases, mandibular in 5 cases, and bimaxillary in 4 cases. The treatment consisted of parathyroidectomy in 13 patients, maxillary resection in 3 cases, and vitamin D treatment in 2 cases. Favorable outcomes, characterized by tumor regression, were reported in 9 cases, whereas unfavorable evolution was observed among 7 patients.

Conclusion

Parathyroidectomy is the gold standard treatment for primary hyperparathyroidism. It resulted in a total regression in all our cases. Regarding secondary hyperparathyroidism, blood screening and chronic renal insufficiency follow-up are critically valuable to detect this condition at an early stage, hence increasing the success rate of brown tumor regression. Our secondary and tertiary hyperparathyroidism results were miscellaneous; although it is important to emphasize the importance of the chronic renal insufficiency management to ensure a success.

Clinical relevance

Brown tumors should be included in the differential diagnosis of giant cell lesions. Parathyroidectomy is usually sufficient to induce the total regression of the lesion in primary hyperparathyroidism cases. A more delicate approach is needed regarding secondary hyperparathyroidism. Meticulous control of chronic renal insufficiency is mandatory in addition to parathyroidectomy.

Parathyroid Imaging

Primary hyperparathyroidism (1° HPT) is a relatively common endocrine disorder usually caused by autonomous secretion of parathormone by one or several parathyroid adenomas. 1° HPT causing hypercalcemia, kidney stones and/or osteoporosis should be treated whenever possible by parathyroidectomy. Accurate preoperative location of parathyroid adenomas is crucial for surgery planning, mostly when performing minimally invasive surgery. Cervical ultrasonography (US) is usually performed to localize parathyroid adenomas as a first intention, followed by 99mTc- sestamibi scintigraphy with SPECT/CT whenever possible. 4D-CT is a possible alternative to 99mTc- sestamibi scintigraphy. Recently, 18F-fluorocholine positron emission tomography/computed tomography (18F-FCH PET/CT) has made its way in the clinics as it is the most sensitive method for parathyroid adenoma detection. It can eventually be combined to 4D-CT to increase its diagnostic performance, although this results in higher dose exposure to the patient. Other forms of hyperparathyroidism consist in secondary (2° HPT) and tertiary hyperparathyroidism (3° HPT). As parathyroidectomy is not usually part of the management of patients with 2° HPT, parathyroid imaging is not routinely performed in these patients. In patients with 3° HPT, total or subtotal parathyroidectomy is often performed. Localization of hyperfunctional glands is an important aid to surgery planning. As 18F-FCH PET/CT is the most sensitive modality in multigland disease, it is the preferred imaging technic in 3° HPT patients, although its cost and availability may limit its widespread use in this setting.

Role of Oral Physician in Diagnosis of Occult Disease of Primary Hyperparathyroidism

Parathyroid hormone (PTH) plays a key role in the regulation of calcium homeostasis. It is secreted by a pair of parathyroid glands located behind the thyroid gland. Primary hyperparathyroidism is the disorder which is seen in 0.2%-0.3% of the population. It is the third most common endocrine disorder after Diabetes Mellitus and Thyroid disorders. There are several systemic manifestations of the disease including skeletal, Renal, abdominal, neurological ones. The following case report discusses some of the classic oral manifestations of the disease and signifies the role of an Oral physician in the diagnosis of underlying systemic disorder.

Maxillary brown tumor due to secondary hyperparathyroidism in a Hemodialysis patient: A case report and literature review

Hemodialysis is one of the commonly used renal replacement therapies in treating end-stage renal failure patients. Patients with long-term dialysis may develop frequently complications such as secondary hyperparathyroidism (SHPT), bone diseases, amyloidosis, endocrinal disturbances, cardiovascular complications and infections. Brown tumors (BTs) are erosive giant cell bony lesions that arise in some patients as a result of primary or SHPT. About 2% of all the reported cases showed involvement of facial skeleton, of which the mandible is the favorite site. A complete clinical, biochemical, radiological and histopathological correlation is required for definitive diagnosis. We report here a case of BT in 37-year-old female hemodialysis patient with SHPT.

Surgical options in treating patients with primary hyperparathyroidism

Background

Primary hyperparathyroidism is the third most common endocrine disorder for which surgical procedure called parathyroidectomy is the most effective treatment. Since the early 20^th century, parathyroid surgery has improved extensively. With the advances in preoperative imaging and with understanding the causes of disease, new and minimally invasive surgical approaches overrode the standard bilateral exploratory operations. Directed parathyroidectomy is currently the standard technique for treatment of primary hyperparathyroidism worldwide.

Conclusions

Surgery is the only definitive treatment of primary hyperparathyroidism. The most appropriate type of surgical procedure depends on the number and localization of the hyperactive parathyroid glands, availability of modern imaging techniques, limitation of each type of procedure and expertise.