J Korean Neurosurg Soc.  2015 Oct;58(4):389-392. 10.3340/jkns.2015.58.4.389.

Brown Tumor of the Thoracic Spine: First Manifestation of Primary Hyperparathyroidism

• Sonmez E
• Tezcaner T
• Coven I
• Terzi A

• KMID: 2114379
• DOI: http://doi.org/10.3340/jkns.2015.58.4.389

Abstract

Brown tumors also called as osteoclastomas, are rare nonneoplastic lesions that arise in the setting of primary or secondary hyperparathyroidism. Parathyroid adenomas or hyperplasia constitute the major Brown tumor source in primary hyperparathyroidism while chronic renal failure is the leading cause in secondary hyperparathyroidism. Most of the patients with the diagnosis of primary hyperparathyroidism present with kidney stones or isolated hypercalcemia. However, nearly one third of patients are asymptomatic and hypercalcemia is found incidentally. Skeletal involvement such as generalized osteopenia, bone resorption, bone cysts and Brown tumors are seen on the late phase of hyperparathyroidism. The symptoms include axial pain, radiculopathy, myelopathy and myeloradiculopathy according to their locations. Plasmocytoma, lymphoma, giant cell tumors and metastates should be ruled out in the differential diagnosis of Brown tumors. Treatment of Brown tumors involve both the management of hyperparathyroidism and neural decompression. The authors report a very rare spinal Brown tumor case, arisen as the initial manifestation of primary hyperparathyroidism that leads to acute paraparesis.

Keyword

Brown tumor; Primary hyperparathyroidism; Spine; Treatment

MeSH Terms

Bone Cysts
Bone Diseases, Metabolic
Bone Resorption
Decompression
Diagnosis
Diagnosis, Differential
Giant Cell Tumors
Humans
Hypercalcemia
Hyperparathyroidism
Hyperparathyroidism, Primary*
Hyperparathyroidism, Secondary
Hyperplasia
Kidney Calculi
Kidney Failure, Chronic
Lymphoma
Paraparesis
Parathyroid Neoplasms
Plasmacytoma
Radiculopathy
Spinal Cord Diseases
Spine*

Figure

• 

  Fig. 1 Sagittal T2W (A), sagittal T1W (B), sagittal T1W postcontrast (C) and axial T2W MR (D) images showing an expansile mass lesion that was compressing the spinal cord at T9 level. Homogenously enhancing mass lesion was found to originate from the anterior portion of the spinous process and both laminas of T9 vertebra.

• 

  Fig. 2 AP (A) and lateral (B) X-Ray images demonstrate a short segment spinal instrumentation and fusion with transpedicular screws and rods at the level of T8-10.

• 

  Fig. 3 A : There is marked resorption of bone trabeculae with marrow fibrosis (left sided) and clustering of osteoclasts that create a brown tumor (right sided) (×40, hematoxylin and eosin staining). B : Clusters of giant cells and hemosiderin-laden macrophages in the fibrous cellular stroma are seen on higher magnification (×200, hematoxylin and eosin staining).

Reference

1. Altan L, Kurtoğlu Z, Yalçinkaya U, Aydinli U, Ertürk E. Brown tumor of the sacral spine in a patient with low-back pain. Rheumatol Int. 2007; 28:77–81. PMID: 17569048.

2. Daras M, Georgakopoulos T, Avdelidis D, Gravani A, Tuchman AJ. Spinal cord compression in primary hyperparathyroidism. Report of a case and review of the literature. Spine (Phila Pa 1976). 1990; 15:238–240. PMID: 2191452.

3. Fargen KM, Lin CS, Jeung JA, Yachnis AT, Jacob RP, Velat GJ. Vertebral brown tumors causing neurologic compromise. World Neurosurg. 2013; 79:208.e1–208.e6. PMID: 22100293.

4. Ganesh A, Kurian S, John L. Complete recovery of spinal cord compression following parathyroidectomy. Postgrad Med J. 1981; 57:652–653. PMID: 7335567.

5. Haddad FH, Malkawi OM, Sharbaji AA, Jbara IF, Rihani HR. Primary hyperparathyroidism. A rare cause of spinal cord compression. Saudi Med J. 2007; 28:783–786. PMID: 17457452.

6. Hoshi M, Takami M, Kajikawa M, Teramura K, Okamoto T, Yanagida I, et al. A case of multiple skeletal lesions of brown tumors, mimicking carcinoma metastases. Arch Orthop Trauma Surg. 2008; 128:149–154. PMID: 17354010.

7. Kashkari S, Kelly TR, Bethem D, Pepe RG. Osteitis fibrosa cystica (brown tumor) of the spine with cord compression : report of a case with needle aspiration biopsy findings. Diagn Cytopathol. 1990; 6:349–353. PMID: 2292220.

8. Khalatbari MR, Moharamzad Y. Brown tumor of the spine in patients with primary hyperparathyroidism. Spine (Phila Pa 1976). 2014; 39:E1073–E1079.

9. Khalil PN, Heining SM, Huss R, Ihrler S, Siebeck M, Hallfeldt K, et al. Natural history and surgical treatment of brown tumor lesions at various sites in refractory primary hyperparathyroidism. Eur J Med Res. 2007; 12:222–230. PMID: 17513195.

10. Lee JH, Chung SM, Kim HS. Osteitis fibrosa cystica mistaken for malignant disease. Clin Exp Otorhinolaryngol. 2013; 6:110–113. PMID: 23799171.

11. Marcocci C, Cianferotti L, Cetani F. Bone disease in primary hyperparathyrodism. Ther Adv Musculoskelet Dis. 2012; 4:357–368. PMID: 23024712.

12. Motateanu M, Déruaz JP, Fankhauser H. Spinal tumour due to primary hyperparathyroidism causing sciatica : case report. Neuroradiology. 1994; 36:134–136. PMID: 8183453.

13. Mustonen AO, Kiuru MJ, Stahls A, Bohling T, Kivioja A, Koskinen SK. Radicular lower extremity pain as the first symptom of primary hyperparathyroidism. Skeletal Radiol. 2004; 33:467–472. PMID: 15221219.

14. Sarda AK, Arunabh , Vijayaraghavan M, Kapur M. Paraplegia due to osteitis fibrosa secondary to primary hyperparathyroidism : report of a case. Surg Today. 1993; 23:1003–1005.

15. Shaw MT, Davies M. Primary hyperparathyroidism presenting as spinal cord compression. Br Med J. 1968; 4:230–231.

16. Shuangshoti S, Hongsaprabhas C, Chandraprasert S, Rajatapiti B. Parathyroid adenoma, brown tumor and cauda equina compression. J Med Assoc Thai. 1972; 55:251–258. PMID: 5022500.

17. Siu K, Sundaram M, Schultz C, Kirwan L. Primary hyperparathyroidism presenting as spinal cord compression : report of a case. Aust N Z J Surg. 1977; 47:668–672.

18. Sundaram M, Scholz C. Primary hyperparathyroidism presenting with acute paraplegia. AJR Am J Roentgenol. 1977; 128:674–676. PMID: 403804.

19. Tayfun H, Metin O, Hakan S, Zafer B, Vardar AF. Brown tumor as an unusual but preventable cause of spinal cord compression : case report and review of the literature. Asian J Neurosurg. 2014; 9:40–44. PMID: 24891890.

20. Yokota N, Kuribayashi T, Nagamine M, Tanaka M, Matsukura S, Wakisaka S. Paraplegia caused by brown tumor in primary hyperparathyroidism. Case report. J Neurosurg. 1989; 71:446–448. PMID: 2769396.