HYPERPARATHYROIDISHYPERPARATHYROIDIS

MM ANDAND

BROWN TUMORBROWN TUMORPrepared by: Amanj M.Mustafa

Supervised by: Dr.Abdulqadir Alani

HYPERPARATHYROIDISHYPERPARATHYROIDISMM

From it is name is :

(Excessive secretion of PTH)

Causes:Primary

Secondary

Tertiary

PathologyPathology

Para thyroid glands, two small paired endocrine glands, superior and inferior, on the posterior surface of the thyroid gland.

PTH enhances calcium level by

stimulating tubular absorption, intestinal absorption and bone resorption.

hypercalcaemia glomerular filtration of calcium hypercalciuria

. Urinary phosphate increased, due to suppressed tubular reabsorption.

calcinosis, stone formation, recurrent infection and impaired function.

Effect on the skeletol Effect on the skeletol systemsystem1.general loss of bone substance

2.osteoclastic hyperactivity produces subperiosteal erosions, endosteal cavitation and replacement of the marrow spaces by vascular granulations and fibrous tissue (osteitis fibrosa cystica).

3. Haemorrhage and giant-cell reaction within the fibrous stroma may give rise to brownish, tumor-like masses, whose liquefaction leads to fluid-filled cysts (brown tumor)

Brown Tumorbrown tumors are a non neoplastic process. On radiographic evaluation their multifocal involvement may be misconstrued as metastatic disease; however, the clinical history of renal failure and hyperparathyroidism usually establishes the diagnosis.

Brown tumors are known to occur only in the setting of hyperparathyroidism.

Symptoms and signs

Hypercalcaemia: anorexia, nausea, abdominal pain, depression,

Fatigue and muscle weakness.

Renal presentation: polyuria, stones or nephrocalcinosis

Skeletal and bone: complain of joint symptoms, due

to chondrocalcinosis. Only a minority (probably less than 10 percent)

present with bone disease; this is usually generalized osteoporosis rather than the classic features of osteitis fibrosa, bone cysts and pathological fractures.

Radiological finding: They appear as single or multiple, well

defined lesions, commonly affecting the facial bones, pelvis, ribs and femoral bone. With treatment Brown tumors may demonstrate healing with increased radiodensity.

osteoporosis and areas of cortical erosion.

The classical – and almost pathognomonic – feature, which should always be sought, is sub-periosteal cortical resorption of the middle phalanges.

Biochemical testsBiochemical tests hypercalcaemia hypophosphataemia serum PTH. Serum alkaline phosphatase with

osteitis fibrosa.

DDXDDX

multiple myelomametastatic diseasesarcoidosis

TreatmentTreatment

Medical :adequate hydration decreased calcium intake.

Surgery:Parathyroidectomystabilisation of the lesion if

mechanical damage has occured

36 YOF36 YOF Presented with Presented with generalized body ache generalized body ache and buttock pain and buttock pain 6months duration.6months duration.Then she started to visit Then she started to visit clinics which 1clinics which 1stst time at time at sept.2010sept.2010

After examination and investigation they found that there is lesion in

the Right iliac bone

(large complex multilocular sexpansile (7*11)cm mass is seen involving left iliac wing extending to the left acetabular articular and inferior part of the left su, the lesion shows vascular flush with main vessel supply from both anterior and posterior trunk of the left internal iliac artery , another similar lesions are seen involving left femoral neck and greater trochanter , Rt iliac wing ( 1.5*2.7)cm, near to the right side sacral ala, small lesion at right side of l5 vertebral body ,

picture suggestive aggressive benign lesion ( fibromatosis)No involving of the pelvic viscera seen

cytopathology cytopathology (No malignant cell (No malignant cell is seen ) is seen ) HistopathologyHistopathologyFibrous cortical Fibrous cortical deffect (Non deffect (Non ossifying fibroma)ossifying fibroma)

The patient prepared The patient prepared for local surgical for local surgical treatment of the treatment of the

lesion lesion

Then in the jan.2011 she Then in the jan.2011 she came to us with the same came to us with the same complaincomplainthat is why we started with that is why we started with complete recheking of the all complete recheking of the all investigations and excluding investigations and excluding of metastasis of metastasis

Results of our rechecking came back as the follwing

CBC showed CBC showed normal other than normal other than decreased monocyte count decreased monocyte count

Alkaline phosphatase 236.4 U/Lcalcium 13.04 mg/dlRBS 112 mg/dlphosphorus 1.7 mg/dlurea 10.8 mg/dl

PTH 232 ng/dl

CT-scan and MRI of the spine, CT-scan and MRI of the spine, abdomen and chestabdomen and chestall of them normalall of them normal

We sent same sample for another lab. We sent same sample for another lab. For biopsyFor biopsy

Smear showedSmear showed sheets of red blood cells, no sheets of red blood cells, no malignant cells or tissue malignant cells or tissue fragments were seen.fragments were seen.

Bone scanBone scanlocal pelvic active lesion? Not local pelvic active lesion? Not suggestive of benign lesion, suggestive of benign lesion, with multiple lesion in the with multiple lesion in the scapula mass suggestive scapula mass suggestive metastasis?? metastasis??

U/S OF THYROID GLAND U/S OF THYROID GLAND conclusion showed conclusion showed (picture of is the left (picture of is the left parathyroid adenoma) parathyroid adenoma)

Referred to general surgeon for doing

surgery

Needle Biopsy of parathyroid SectionNeedle Biopsy of parathyroid Section

revealed parathyroid revealed parathyroid adenoma, with remnant of adenoma, with remnant of normal parathyroid tissue , normal parathyroid tissue , no malignancy no malignancy

POST OP FOLLOW UP for about 6 months after parathyredectomy we found that

The symptom of pelvic pain completely abolished and pt looks well

Lytic lesion completely disappeared without any local surgical intervension

After 6 months

After 6 monthsAfter 6 months

References: Apley s system of orthopaedics and fractures( ninth

edition) Campbells operative orthopaedics

(eleventh edition) Color atlas of clinical orthopaedics Essentials of orthopaedic surgery Davidson principles and practice of medine

19th edition Muirs textbook of pathology ( eleventh edition)