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OSTEOPOROSIS & OSTEOPOROSIS & OSTEOLYSIS IN OSTEOLYSIS IN

HYPERPARATHYROIDISMHYPERPARATHYROIDISM

OSTEOPOROSIS & OSTEOPOROSIS & OSTEOLYSIS IN OSTEOLYSIS IN

HYPERPARATHYROIDISMHYPERPARATHYROIDISM

Lê Chí DũngLê Chí Dũng, MD, PhD, MD, PhD

HTO, VietnamHTO, Vietnam

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Hospital for Traumatology & Orthopaedics (HTO), HCMC

PARATHYROID TUMORSPARATHYROID TUMORS

Very rare.

Hypersecretion of PTH causes many bone lesions & other disorders in the context of “Hyperparathyroidism”.

Study of 10 cases of hyperparathyroidism treated at HTO from 1985-2008.

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DIAGNOSISDIAGNOSIS

Clinical examination: Clinical examination: palpable tumor at thyroid region ±, lower pole±, lower pole…; bone lesions…; bone lesions

Laboratory: Laboratory: CalCalcemia, , Phosphoremia

PTH Ultrasound: ++Ultrasound: ++

MRI : +++MRI : +++

Surgical pathology: Surgical pathology: confirm the diagnosis ucgucg55

10 cases / 23 years10 cases / 23 years 8 females / 2 males : 25 8 females / 2 males : 25 56 y.o. 56 y.o.

Tran T.B. HUYEN, 25 y.o., HCMC. Tran T.B. HUYEN, 25 y.o., HCMC. 8731 / 85 8731 / 85 Tran T. NHUNG , 34 y.o., Dong Nai. Tran T. NHUNG , 34 y.o., Dong Nai. BH / 98 BH / 98 Nguyen T.K. DINH , 43 y.o., Daklak. Nguyen T.K. DINH , 43 y.o., Daklak. 77 BH / 99 77 BH / 99 Doan T. K. EN, 32 y.o., Long An. Doan T. K. EN, 32 y.o., Long An. 296BH/99296BH/99 Tran K. LOAN, 42 y.o., HCMC. Tran K. LOAN, 42 y.o., HCMC. 197 BH/00197 BH/00 Vu V. KY, 48 y.o., tpHCM. Vu V. KY, 48 y.o., tpHCM. 566BH/00566BH/00 Nguyen T.B. THUY, 36 y.o., An Giang Nguyen T.B. THUY, 36 y.o., An Giang 623BH/01623BH/01 Do T. M. MOT, 45 y.o., Vinh Long. Do T. M. MOT, 45 y.o., Vinh Long. 286286 BH/02 BH/02 Nguyen V. THIEÄP, 56 y.o., Ben Tre. Nguyen V. THIEÄP, 56 y.o., Ben Tre. 130 BH/08130 BH/08 Le T. MEÁN, 32 y.o., Lam Dong. Le T. MEÁN, 32 y.o., Lam Dong. 209 BH/08209 BH/08

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OBJECTIVES OF OBJECTIVES OF STUDYSTUDY

Radiographic findings of boRadiographic findings of bone lesionsne lesions

Microscopic aspects of parathyroid tumors & of Microscopic aspects of parathyroid tumors & of

bone lesionsbone lesions

Changes of bone lesions under the treatmentChanges of bone lesions under the treatment

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METHODS OF STUDYMETHODS OF STUDY

TreatmentTreatment:: • Pre-op.: Calcitonin / BisphosphonatePre-op.: Calcitonin / Bisphosphonate• Resection of parathyroid tumorResection of parathyroid tumor• Post-op.: high dose of Calcitriol + CalciumPost-op.: high dose of Calcitriol + Calcium Symptomatic management Symptomatic management (for bone (for bone

fractures, nephrolithiasis...)fractures, nephrolithiasis...)

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Determination of Determination of bonebone lesionslesions based mainly on based mainly on conventional radiography, sometimes on DEXA, CT conventional radiography, sometimes on DEXA, CT

scan…scan…

Surgical pathologySurgical pathology : : Hematoxylin-EosinHematoxylin-Eosin

BONE LESIONSBONE LESIONSRadiographic findings – 10 CASES

Generalised Osteoporosis 9 Generalised Osteoporosis 9 Subperiosteal bone resorption 9 Subperiosteal bone resorption 9 Compression fractures of vertebral body 7Compression fractures of vertebral body 7 Height loss 6Height loss 6 ““Brown tumor”Brown tumor” 6 6 Past history of fractures 6Past history of fractures 6 Stress fractures 5Stress fractures 5 Subperiosteal bone resorption of phalanges Subperiosteal bone resorption of phalanges 44 Curved deformation of lower limb 4Curved deformation of lower limb 4 Vertebral scoliosis 3Vertebral scoliosis 3 Absence of lamina dura of teeth Absence of lamina dura of teeth 22

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BONE LESIONSBONE LESIONS Radiographic findings

2 groups :2 groups :

• OsteoporosisOsteoporosis• Bone Resorption / Osteolysis Bone Resorption / Osteolysis

COMPLICATIONSCOMPLICATIONS : : Bone FracturesBone Fractures

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SURGICAL PATHOLOGYSURGICAL PATHOLOGY

10 parathyroid tumor : 1,5-4 cm

chief cell typechief cell type 9 9 oxyphil cell type 1oxyphil cell type 1

Cellular atypia :Cellular atypia : - none 8- none 8

- mild 1- mild 1 - moderate 1- moderate 1

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SURGICAL PATHOLOGYSURGICAL PATHOLOGY

8 parathyroid adenoma8 parathyroid adenoma

2 tumors with cellular atypia => benign or 2 tumors with cellular atypia => benign or malignant ? :malignant ? :

* * macroscopy: no invasionmacroscopy: no invasion no distant metastasisno distant metastasis

* good outcome of treatment after 5 yrs* good outcome of treatment after 5 yrs Benign tumorsBenign tumors (parathyroid adenomas) (parathyroid adenomas)

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Traàn Thò Bích H. Traàn Thò Bích H. F, 25 y.o.F, 25 y.o.

8731 / 85 , 9 / 85 -Surgery 10 / 858731 / 85 , 9 / 85 -Surgery 10 / 85 1 yr : 1 yr : bone pain, sensation of fatigue, bone pain, sensation of fatigue,

heigh loss 5cm.heigh loss 5cm. Tumor Tumor at (R) lower thyroid gl.1,5 cmat (R) lower thyroid gl.1,5 cm Radio. : Radio. : generalised osteoporosis , generalised osteoporosis ,

compression fx of vertebral bodies compression fx of vertebral bodies Pathology : Parathyroid adenomaPathology : Parathyroid adenoma ucg 4ucg 4

H., 25F, Heigh loss 5cm - Compression Fx of vertebrae- H., 25F, Heigh loss 5cm - Compression Fx of vertebrae- Osteporosis Osteporosis

HistopathologyHistopathology : Parathyroid Adenoma 2cm, : Parathyroid Adenoma 2cm, oxyphil cell typeoxyphil cell type

Traàn Kim L., 42y.o.Traàn Kim L., 42y.o.197BH/00 , 197BH/00 , 03 / 00 - Surgery 04/0003 / 00 - Surgery 04/00

ClinicsClinics : : Tumor of tibia 1yr,Tumor of tibia 1yr,

No palpable parathyroid tumorNo palpable parathyroid tumor LabLab. : . : Hypercalcemia 5,8 mEq/l, Hypercalcemia 5,8 mEq/l,

alkaline phosphatasealkaline phosphatase RadioRadio: : Osteolysis of proximal tibia, scoliosis Osteolysis of proximal tibia, scoliosis

generalised osteoporosis generalised osteoporosis

SonographySonography : (L): (L) Parathyroid tumorParathyroid tumor 26x12mm, 26x12mm,

(R) Renal calculus 7mm(R) Renal calculus 7mm Clinical diagnosisClinical diagnosis : Metastatic Carcinoma !? : Metastatic Carcinoma !?

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K. L., 42 y.o., F, Brown Tumor of TibiaK. L., 42 y.o., F, Brown Tumor of Tibia

K.L., Biopsy at the tumor of tibia: “Brown tumor”K.L., Biopsy at the tumor of tibia: “Brown tumor”

K.L., Parathyroid Adenoma, chief cell typeK.L., Parathyroid Adenoma, chief cell type

Vuõ Vaên K., 48y.o.Vuõ Vaên K., 48y.o.

566BH/00 , 566BH/00 , 26 / 09 / 00 - Surgery 10/0026 / 09 / 00 - Surgery 10/00 Past historyPast history : : 4yrs Bone pain4yrs Bone pain Clinics : Clinics : Heigh loss 6cm, limb Heigh loss 6cm, limb

discrepancy.discrepancy.No palpable parathyroid TNo palpable parathyroid TOO

Lab. : Lab. : Calcemia 5 mEq/lCalcemia 5 mEq/l RadioRadio: : Generalised osteoporosis & Generalised osteoporosis &

osteolysis, Compressive Fx of vertebraeosteolysis, Compressive Fx of vertebrae DEXA DEXA : O: Osteoporosis, Tscore:-3.59steoporosis, Tscore:-3.59

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K, 48y.o, M, Subperiosteal & K, 48y.o, M, Subperiosteal & Subendosteal resorption of Ischium, Subendosteal resorption of Ischium,

Femur & TibiaFemur & Tibia

K, Expansile loculated Brown Tumor of K, Expansile loculated Brown Tumor of Metacarpals 2-5Metacarpals 2-5

Bone Scan: Hot spot of calvaria, Bone Scan: Hot spot of calvaria, mandible, ribs, femurs, tibias...mandible, ribs, femurs, tibias...

VUÕ VAÊN KYÙ, 48y.o.VUÕ VAÊN KYÙ, 48y.o.

Clinico-radiological diagnosis : Clinico-radiological diagnosis : Metastatic Ca. or Parathyroid tumor ?Metastatic Ca. or Parathyroid tumor ?

Sonography, MRI :Sonography, MRI :(L) Parathyroid T. (L) Parathyroid T.

Biopsy Biopsy of foot lesions : Brown Tof foot lesions : Brown TOO

SurgerySurgery 10 / 00 : Resection of 10 / 00 : Resection of Parathyroid Tumor. Parathyroid Tumor.

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MRI : MRI : ParathyroParathyroid Tumorid Tumor

of (L) of (L) inferior inferior gland gland

Moderate Cellular AtypiaModerate Cellular Atypia => => Adenoma or Carcinoma ??? Adenoma or Carcinoma ??? ADENOMAADENOMA

RESULTS OF TREATMENTRESULTS OF TREATMENT

Obvious amelioration of health Obvious amelioration of health Good appetite, sleepGood appetite, sleep Dimunition of musculo-skeletal pain after 3mthsDimunition of musculo-skeletal pain after 3mths No tetany nor muscular spasmNo tetany nor muscular spasm

Paresthesia of distal limb persist for 6 mthsParesthesia of distal limb persist for 6 mths

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Traàn Thò N., 34 y.o.Traàn Thò N., 34 y.o.

49 BH / 99 , 8 / 1 / 98 - Surgery 12 / 9849 BH / 99 , 8 / 1 / 98 - Surgery 12 / 98

1 yr : 1 yr : knee painknee pain * * 7 mth : 7 mth : clavicle fx.clavicle fx.

5 mth : 5 mth : fatigue, back painfatigue, back pain -> -> arthralgiaarthralgia

CLINIC : CLINIC : heigh lossheigh loss 5 cm 5 cm - - kyphosiskyphosis

llimb weaknessimb weakness - - body contractionbody contraction

No palpable parathyroid tumorNo palpable parathyroid tumor

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Fatigue, Heigh loss, Fatigue, Heigh loss, ScoliosisScoliosis

Traàn Thò N., 34 y.o.Traàn Thò N., 34 y.o.

Radio. : Radio. : Osteoporosis, renal calculusOsteoporosis, renal calculus Sonography : Sonography : 3st time: 3st time: No parathyroid tumor No parathyroid tumor ? ? 4th time : Parathyroid tumor (+) MRI : MRI : No parathyroid tumor No parathyroid tumor (2). PT (+) 3(2). PT (+) 3rdrd time time LAB. : LAB. : Hypercalcemia 6,8 mEq / lHypercalcemia 6,8 mEq / l

Testing Treatment : Testing Treatment : good response with good response with Miacalcic + CaC + Vit ADMiacalcic + CaC + Vit AD

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RADIOGRAPHYRADIOGRAPHY-Generalised Osteoporosis, -Generalised Osteoporosis,

Subperiosteal OsteolysisSubperiosteal Osteolysis

33rdrd MRI MRI - Parathyroid - Parathyroid Tumor at the (L) Tumor at the (L) inferior gland inferior gland

HistopathologyHistopathology : Parathyroid T. with mild : Parathyroid T. with mild cellular atypiacellular atypia

3 yrs post-3 yrs post-opop

Good Good Response with Response with

treatmenttreatment

RESULTS OF TREATMENTRESULTS OF TREATMENT

Aspects of osteoporosis & osteolysis do not Aspects of osteoporosis & osteolysis do not change on radiography for 9 mths though change on radiography for 9 mths though patient feel less painful after 3 mths. patient feel less painful after 3 mths.

Osteoporosis aspects will be improved Osteoporosis aspects will be improved clearly 1 yr later.clearly 1 yr later.

““Brown tumor” : Brown tumor” : reactive osteoslerosis 2 reactive osteoslerosis 2 mths post-op.; cortical reconstruction 6 mths post-op.; cortical reconstruction 6 mths post-op.mths post-op.

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RESULTS OF TREATMENTRESULTS OF TREATMENT

Stress / pathologic fractures : Stress / pathologic fractures : callus seen callus seen at 3 mths post-op. with less or no painat 3 mths post-op. with less or no pain ..

Bone healing Bone healing with osteosclerosis attain at with osteosclerosis attain at 2-3 yrs later2-3 yrs later..

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Nguyen T. K. Đ., 43 y.o.Nguyen T. K. Đ., 43 y.o.

77 BH / 99 , 77 BH / 99 , 8 / 1 / 99 - Surgery 3 / 998 / 1 / 99 - Surgery 3 / 99 Past historyPast history : : Renal calculiRenal calculi 3 mth : 3 mth : MVA -> bone Fx ? -> CastMVA -> bone Fx ? -> Cast 1,5 mth : 1,5 mth : ablation of cast -> Tablation of cast -> TOO -> CTO -> CTO ClinicsClinics : : (R) thyroid tumor 2 cm(R) thyroid tumor 2 cm RadioRadio: : Osteolysis of (L) tibiOsteolysis of (L) tibia,(R) a,(R) femur femur

(L) 4th rib(L) 4th rib --> -->Metastatic thyroid Ca. ?Metastatic thyroid Ca. ?

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Nguyen T. K. Đ., 43 y.o.Nguyen T. K. Đ., 43 y.o. 8/ 1/ 998/ 1/ 99 : biopsy of Tibial T. - 376 YK - : biopsy of Tibial T. - 376 YK -

> > suggestion of hyperparathyroidismsuggestion of hyperparathyroidism 21/1/9921/1/99 : tumor curettage + I.M. : tumor curettage + I.M.

nailing + bone graftnailing + bone graft

Same microscopic featuresSame microscopic features -737 YK -737 YK 25/3/9925/3/99 : : Parathyroid tumor resection, Parathyroid tumor resection,

3cm3cm Patho.2321 YK: Parathyroid adenoma Patho.2321 YK: Parathyroid adenoma ucg 16ucg 16

Ñ, 43 y.o., F, Parathyroid AdenomaÑ, 43 y.o., F, Parathyroid Adenoma

D., 43 y.o., F,D., 43 y.o., F,

““Brown Tumor”Brown Tumor”

of Tibiaof Tibia

Parathyroid AdenomaParathyroid Adenomachief cell typechief cell type

““Brown tumor” at (L) tibiaBrown tumor” at (L) tibia

Stress Fracture healingStress Fracture healing

Stress Fracture healingStress Fracture healing

Nguyen Van T., 56 y.o. Nguyen Van T., 56 y.o. 130 BH/08: 27/02 – 06/03/08130 BH/08: 27/02 – 06/03/08

Bone mass with osteoporosis / osteolysis / multiple fractures

ULTRASOUND: bilateral nodules, (L) thyroid cyst. Parathyroid Tumor (-).

T-score: -3,88

PTH 699,4 pg/mL (N: 16-65pg/mL)

(L) Thyroid Cyst? => Parathyroid Adenoma!.

Nguyen Van T., 56 y.o. Nguyen Van T., 56 y.o. 3 mths pre-op. 6 mths post-op. + medicine 3 mths pre-op. 6 mths post-op. + medicine

Hip Hip fracture fracture healinghealing

Nguyen Van T., 56 y.o. Nguyen Van T., 56 y.o. 3 mths pre-op. 2 yrs post-op. 3 mths pre-op. 2 yrs post-op.

Osteolysis (brown Tumor) Osteolysis (brown Tumor) of lateral malleolusof lateral malleolus

Healing of bone lesionHealing of bone lesion

HYPERPARATHYROIDISMHYPERPARATHYROIDISM

Very rare, 25 - 56 y.o., 8F / 2M during 23 yrsVery rare, 25 - 56 y.o., 8F / 2M during 23 yrs

Due to PARATHYROID TUMORS Due to PARATHYROID TUMORS Very late, all presented bone lesionsVery late, all presented bone lesions

CLINICO - RADIO.CLINICO - RADIO. : osteoporosis, osteolysis, : osteoporosis, osteolysis, fracture, fatigue, heigh loss, kidney stone, fracture, fatigue, heigh loss, kidney stone, pseudotumor of bone (pseudotumor of bone (Brown TBrown TOO))

Parathyroid tumor : ± Parathyroid tumor : ±

PARATHYROID TUMORPARATHYROID TUMOR

Ultrasound, MRI, Surgical Pathology (+)Ultrasound, MRI, Surgical Pathology (+)

Adenoma, good prognosis Adenoma, good prognosis

Carcinoma : very rare, based on invasion, Carcinoma : very rare, based on invasion, distant metastasis distant metastasis

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PARATHYROID ADENOMAPARATHYROID ADENOMA Management : Management : tumor resection + appropiate tumor resection + appropiate

pre. & post-op. medication.pre. & post-op. medication.

Results of treatment :Results of treatment :* * General status : goodGeneral status : good

* * Musculo-skeletal Symptoms : early improvedMusculo-skeletal Symptoms : early improved

Bone lesions seen on radiography : lately Bone lesions seen on radiography : lately improved, need 1-2 yrs.improved, need 1-2 yrs.

Very difficult to manage in many cases!Very difficult to manage in many cases!

HOW TO DETECT & DIAGNOSE EARLYHOW TO DETECT & DIAGNOSE EARLY !!! !!!

THANKS !