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Year : 2022  |  Volume : 37  |  Issue : 3  |  Page : 288-289  

Brown Tumors Secondary to Tertiary Hyperparathyroidism Masquerading as Lytic or Sclerotic Skeletal Metastases on Preoperative/Postoperative 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography: A Case Report


Department of Nuclear Medicine, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey

Date of Submission06-Dec-2021
Date of Decision15-Feb-2022
Date of Acceptance23-Feb-2022
Date of Web Publication02-Nov-2022

Correspondence Address:
Prof. Tunc Ones
Marmara University Istanbul Pendik Training and Research Hospital Muhsin Yazicioglu Street No: 10 Pendik, Istanbul 34899
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnm.ijnm_195_21

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   Abstract 


Tertiary hyperparathyroidism (TH) is a rare condition that develops from secondary hyperparathyroidism in cases when the secretion becomes autonomous. Brown tumors (BTs) are rare skeletal lesions of hyperparathyroidism that may mimic cancer metastasis. We report a case of a patient who was diagnosed with TH with multiple BTs which mimics osteolytic/osteoblastic metastases that were evaluated with two fluorodeoxyglucose positron emission tomography scans with an interval of 23 months in the preoperative and postoperative period.

Keywords: Brown tumors, fluorodeoxyglucose positron emission tomography/computed tomography, osteoblastic metastases, osteolytic metastases, tertiary hyperparathyroidism


How to cite this article:
Engur CO, Ones T, Filizoglu N, Kesim S, Ozguven S. Brown Tumors Secondary to Tertiary Hyperparathyroidism Masquerading as Lytic or Sclerotic Skeletal Metastases on Preoperative/Postoperative 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography: A Case Report. Indian J Nucl Med 2022;37:288-9

How to cite this URL:
Engur CO, Ones T, Filizoglu N, Kesim S, Ozguven S. Brown Tumors Secondary to Tertiary Hyperparathyroidism Masquerading as Lytic or Sclerotic Skeletal Metastases on Preoperative/Postoperative 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography: A Case Report. Indian J Nucl Med [serial online] 2022 [cited 2022 Nov 29];37:288-9. Available from: https://www.ijnm.in/text.asp?2022/37/3/288/360268



A 43-year-old renal transplant recipient with multiple lytic bone lesions on thoracic computed tomography (CT), which were evaluated in favor of metastasis, was referred to 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT scan to detect the primary focus. The patient had a complaint of generalized bone pain. In the first PET scan, intense hypermetabolic lytic destructive multiple lesions were observed in the skeleton [[Figure 1] arrows in a-c]. A few months ago, dual-phase Tc-99m-MIBI parathyroid scintigraphy was also performed due to high parathormone level (parathyroid hormone [PTH]: 892 pg/mL and Ca: 8.1 mg/dL) and showed parathyroid adenomas at the inferior neighborhood of both lobes of the thyroid gland. The PET scan findings were considered highly suggestive of multiple brown tumors (BTs) secondary to tertiary hyperparathyroidism (TH). Subsequently, parathyroidectomy was performed for TH. The postoperative PTH level was decreased from admission levels to 38 pg/mL. Clinical manifestations receded after surgical treatment. Twenty-three months after the surgical procedure, the patient was evaluated with a new PET scan for symptoms of anemia and weight loss. The second PET scan revealed multiple sclerotic bone lesions in the skeleton which were described as intensely hypermetabolic lytic destructive lesions previously [[Figure 1] arrows in d-f]. There are some publications in the literature about the FDG uptake in BTs.[1],[2],[3],[4] Although they are benign lesions, BTs, giant cell reparative granulomas, aneurysmal bone cysts, giant cell tumors of bone, and osteoclast-like giant cell-containing lesions of bone show increased FDG uptake in favor of malignancy.[5],[6],[7],[8],[9],[10],[11] These benign lesions contain giant cells and/or histiocytes derived from monocyte-macrophage group and provide their energy mostly by glucose metabolism.[12],[13] BTs similarly contain mononuclear cells and fibroblasts derived from the same cell group.[13] It should be kept in mind that BTs can imitate both osteolytic and osteosclerotic metastases depending on the surgical history, especially in patients with diagnosed TH.
Figure 1: The second PET scan revealed multiple sclerotic bone lesions (d,-f) in the skeleton which were described as intensely hypermetabolic lytic destructive lesions previously (a-c)

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Tsushima Y, Sun S, Via MA. Brown tumors secondary to parathyroıd carcınoma masqueradıng as skeletal metastases on 18F-FDG PET/CT: A case report. AACE Clin Case Rep 2019;5:e230-2.  Back to cited text no. 1
    
2.
Gahier Penhoat M, Drui D, Ansquer C, Mirallie E, Maugars Y, Guillot P. Contribution of 18-FDG PET/CT to brown tumor detection in a patient with primary hyperparathyroidism. Joint Bone Spine 2017;84:209-12.  Back to cited text no. 2
    
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Gedik GK, Ata O, Karabagli P, Sari O. Differential diagnosis between secondary and tertiary hyperparathyroidism in a case of a giant-cell and brown tumor containing mass. Findings by (99m) Tc-MDP, (18) F-FDG PET/CT and (99m) Tc-MIBI scans. Hell J Nucl Med 2014;17:214-7.  Back to cited text no. 3
    
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Aoki J, Watanabe H, Shinozaki T, Takagishi K, Ishijima H, Oya N, et al. FDG PET of primary benign and malignant bone tumors: Standardized uptake value in 52 lesions. Radiology 2001;219:774-7.  Back to cited text no. 5
    
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O'Connor W, Quintana M, Smith S, Willis M, Renner J. The hypermetabolic giant: 18F-FDG avid giant cell tumor identified on PET-CT. J Radiol Case Rep 2014;8:27-38.  Back to cited text no. 6
    
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Costelloe CM, Chuang HH, Madewell JE. FDG PET/CT of primary bone tumors. AJR Am J Roentgenol 2014;202:W521-31.  Back to cited text no. 7
    
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Tripathi M, Kumar R, Mohapatra T, Nadig M, Bal C, Malhotra A. Intense F-18 FDG uptake noted in a benign bone cyst. Clin Nucl Med 2007;32:255-7.  Back to cited text no. 8
    
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Makis W, Hickeson M. Spindle cell sarcoma degeneration of giant cell tumor of the knee, imaged with F-18 FDG PET-CT and Tc-99m MDP bone scan. Clin Nucl Med 2010;35:112-5.  Back to cited text no. 9
    
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Park HJ, Kwon SY, Cho SG, Kim J, Song HC, Kim SS, et al. Giant cell tumor with secondary aneurysmal bone cyst shows heterogeneous metabolic pattern on 18F-FDG PET/CT: A case report. Nucl Med Mol Imaging 2016;50:348-52.  Back to cited text no. 10
    
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Zhang Y, Reeve IP, Lewis DH. A case of giant cell tumor of sacrum with unusual pulmonary metastases: CT and FDG PET findings. Clin Nucl Med 2012;37:920-1.  Back to cited text no. 11
    
12.
Mészáros K, Lang CH, Bagby GJ, Spitzer JJ. Contribution of different organs to increased glucose consumption after endotoxin administration. J Biol Chem 1987;262:10965-70.  Back to cited text no. 12
    
13.
Gamelli RL, Liu H, He LK, Hofmann CA. Augmentations of glucose uptake and glucose transporter-1 in macrophages following thermal injury and sepsis in mice. J Leukoc Biol 1996;59:639-47.  Back to cited text no. 13
    


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