A 48-year-old woman with chronic renal failure (CHF) on haemodialysis and history of renal transplantation rejection presented with abdominal and left hip pain for a few months and a high parathyroid hormone (PTH) level.
Thoraco-abdominopelvic unenhanced CT was performed, in a patient with asthma and history of previous adverse reaction to intravenous contrast. Several osseous lytic lesions were identified (figures 1 to 3), including the mandible (not shown), vertebral axis (figure 1) and pelvic bones (figures 2 and 3).
Ultrasound guided biopsy of the left iliac lesion was performed. Histology showed "giant-cell tumour". After failure of medical treatment, total parathyroidectomy was performed and a follow-up CT is shown (figure 4).
Brown tumours (BT) are not true neoplasms, but rather a form of cystic fibrous osteitis, a reparative process that replaces bone for fibroellastic tissue in a context of intense osteoclastic activity [1]. BT are a manifestation of primary or secondary hyperparathyroidism and usually occur late in the course of the disease [2], being more common among women older than 50 years [3]. Chronic renal failure is a well-established cause of secondary hyperthyroidism, and high levels of PTH are related to hipocalcemia, hyperphosphatemia and calcitriol deficiency seen in CRF patients [4]. BT frequent locations include ribs, clavicles, pelvis, femur and facial bones, the latter particularly in the mandible [5]. Lesions are lytic, well-defined, mono or polyostotic, sometimes accompanied by pain at the site. Subperiosteal bone resorption is also an important finding in patients with hyperparathyroidism [6]. Differential diagnosis depends on the number of lesions and their location(s), and includes mainly fibrous dysplasia, infection, multiple myeloma and metastasis (particularly if polyostotic) and giant cell tumor (particularly if located at meta-epiphyseal regions of long bones). Histologically BT are characterized by the presence of multiple giant cells, intraosseous bleedding and tissue degeneration leading to cystic space formation [7]. Similar pattern can be observed in giant cell tumours, fibrous dysplasia and reparative granuloma, so clinical, analytic and imaging elements are of paramount importance to correctly make the diagnosis. Treatment include medical and surgical options for controlling PTH levels, the latter being commonly reserved for refractory cases. BT lesions usually undergo rapid sclerosis after PTH levels normalize [6].
Take home message:
Multiple lytic lesions in context of high PTH levels should always raise suspiction for BT.
Brown Tumors of Hyperparathyroidism
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From the provided CT images of the abdomen and pelvis, multiple lucent (lytic) bone lesions are visible, with relatively clear margins, primarily involving the pelvis, iliac bones, proximal femurs, and parts of the ribs. Some lesions exhibit a cystic or expansile appearance, with local destruction of the bone structure. Considering the patient’s medical history and elevated PTH (parathyroid hormone) level, a significant abnormality in bone metabolism is suggested. No obvious acute fracture signs are observed, but there may be a risk of chronic pain or potential fractures at the lesion sites. No significant soft tissue swelling or abnormal soft tissue mass is noted around some of the lesions.
Based on the imaging characteristics (multiple lytic lesions, some appearing cystic) and the patient’s underlying conditions (chronic renal failure, long-term hemodialysis, elevated PTH), possible diagnoses include:
Considering the patient’s elevated PTH level, chronic renal failure history, and imaging findings of multiple lytic lesions involving typical sites such as the iliac bones and femurs, the most likely diagnosis is:
Brown Tumor due to secondary hyperparathyroidism.
If uncertainty remains, a bone biopsy could be performed if necessary to further confirm or rule out other rare conditions.
The goals of rehabilitation include alleviating bone pain, maintaining or improving muscle strength, preventing fractures, and enhancing quality of life. Exercise programs should be individualized based on the patient’s current bone condition and overall status, with a gradual progression.
By integrating these interventions and adopting a structured rehabilitation approach, symptoms can be alleviated and the patient’s quality of life improved.
This report is a reference-based medical analysis derived from the information currently available. It does not replace face-to-face consultation or the diagnosis and treatment advice of a qualified physician. If you have any questions or experience changes in your condition, please seek professional help from a registered medical institution promptly.
Brown Tumors of Hyperparathyroidism
