1. Welcome to Hochiminh City – Vietnam

2. OSTEOPOROSIS & OSTEOLYSIS IN HYPERPARATHYROIDISM Lê Chí Dũng, MD, PhD HTO, Vietnam ucg 1 ucg 1

3. Hospital for Traumatology & Orthopaedics (HTO), HCMC

4. PARATHYROID TUMORS n n Very rare. n n Hypersecretion of PTH causes many bone lesions & other disorders in the context of “Hyperparathyroidism”. n n Study of 10 cases of hyperparathyroidism treated at HTO from 1985-2008. ucg4 ucg4

5. DIAGNOSIS Clinical examination: ±, lower pole…; bone lesions Clinical examination: palpable tumor at thyroid region ±, lower pole…; bone lesions n Laboratory: Cal, n Laboratory:  Calcemia, Phosphoremia  PTH n Ultrasound: ++ n MRI : +++ n Surgical pathology: n Surgical pathology: confirm the diagnosis ucg5 ucg5

6. 10 cases / 23 years 8 females / 2 males : 25  56 y.o. Tran T.B. HUYEN, 25 y.o., HCMC. 8731 / 85 Tran T.B. HUYEN, 25 y.o., HCMC. 8731 / 85 Tran T. NHUNG, 34 y.o., Dong Nai. BH / 98 Tran T. NHUNG, 34 y.o., Dong Nai. BH / 98 Nguyen T.K. DINH, 43 y.o., Daklak. 77 BH / 99 Nguyen T.K. DINH, 43 y.o., Daklak. 77 BH / 99 Doan T. K. EN, 32 y.o., Long An. 296BH/99 Doan T. K. EN, 32 y.o., Long An. 296BH/99 Tran K. LOAN, 42 y.o., HCMC. 197 BH/00 Tran K. LOAN, 42 y.o., HCMC. 197 BH/00 Vu V. KY, 48 y.o., tpHCM. 566BH/00 Vu V. KY, 48 y.o., tpHCM. 566BH/00 Nguyen T.B. THUY, 36 y.o., An Giang 623BH/01 Nguyen T.B. THUY, 36 y.o., An Giang 623BH/01 Do T. M. MOT, 45 y.o., Vinh Long. 286 BH/02 Do T. M. MOT, 45 y.o., Vinh Long. 286 BH/02 Nguyen V. THIEÄP, 56 y.o., Ben Tre. 130 BH/08 Nguyen V. THIEÄP, 56 y.o., Ben Tre. 130 BH/08 Le T. MEÁN, 32 y.o., Lam Dong. 209 BH/08 Le T. MEÁN, 32 y.o., Lam Dong. 209 BH/08 ucg6 ucg6

7. OBJECTIVES OF STUDY n Radiographic findings of bone lesions n Microscopic aspects of parathyroid tumors & of bone lesions n Changes of bone lesions under the treatment ucg7 ucg7

8. METHODS OF STUDY n Treatment: Pre-op.: Calcitonin / Bisphosphonate Pre-op.: Calcitonin / Bisphosphonate Resection of parathyroid tumor Resection of parathyroid tumor Post-op.: high dose of Calcitriol + Calcium Post-op.: high dose of Calcitriol + Calcium Symptomatic management (for bone fractures, nephrolithiasis...) ucg8 ucg8 Determination of bone lesions based mainly on conventional radiography, sometimes on DEXA, CT scan… Surgical pathology : Hematoxylin-Eosin

10. BONE LESIONS BONE LESIONS Radiographic findings – 10 CASES Generalised Osteoporosis 9 Generalised Osteoporosis 9 Subperiosteal bone resorption 9 Subperiosteal bone resorption 9 Compression fractures of vertebral body 7 Compression fractures of vertebral body 7 Height loss 6 Height loss 6 “Brown tumor” 6 “Brown tumor” 6 Past history of fractures 6 Past history of fractures 6 Stress fractures 5 Stress fractures 5 Subperiosteal bone resorption of phalanges 4 Subperiosteal bone resorption of phalanges 4 Curved deformation of lower limb 4 Curved deformation of lower limb 4 Vertebral scoliosis 3 Vertebral scoliosis 3 Absence of lamina dura of teeth 2 Absence of lamina dura of teeth 2 ucg10 ucg10

11. BONE LESIONS BONE LESIONS Radiographic findings n 2 groups : Osteoporosis Osteoporosis Bone Resorption / Osteolysis Bone Resorption / Osteolysis n COMPLICATIONS : Bone Fractures ucg11 ucg11

12. SURGICAL PATHOLOGY 10 parathyroid tumor : 1,5-4 cm chief cell type 9 chief cell type 9 oxyphil cell type 1 oxyphil cell type 1 Cellular atypia : Cellular atypia : - none 8 - none 8 - mild 1 - mild 1 - moderate 1 - moderate 1 ucg12 ucg12

13. SURGICAL PATHOLOGY n 8 parathyroid adenoma n 2 tumors with cellular atypia => benign or malignant ? : * macroscopy: no invasion no distant metastasis no distant metastasis * good outcome of treatment after 5 yrs  Benign tumors (parathyroid adenomas) ucg13 ucg13

14. Traàn Thò Bích H. F, 25 y.o. 8731 / 85, 9 / 85 -Surgery 10 / 85 8731 / 85, 9 / 85 -Surgery 10 / 85 1 yr : bone pain, sensation of fatigue, heigh loss 5cm. 1 yr : bone pain, sensation of fatigue, heigh loss 5cm. Tumor at (R) lower thyroid gl.1,5 cm Tumor at (R) lower thyroid gl.1,5 cm Radio. : generalised osteoporosis, compression fx of vertebral bodies Radio. : generalised osteoporosis, compression fx of vertebral bodies Pathology : Parathyroid adenoma Pathology : Parathyroid adenoma ucg 4 ucg 4

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

16. Histopathology : Parathyroid Adenoma 2cm, oxyphil cell type 

17. Traàn Kim L., 42y.o. 197BH/00, 03 / 00 - Surgery 04/00 Clinics : Tumor of tibia 1yr, Clinics : Tumor of tibia 1yr, No palpable parathyroid tumor No palpable parathyroid tumor Lab. : Hypercalcemia 5,8 mEq/l, Lab. : Hypercalcemia 5,8 mEq/l,  alkaline phosphatase  alkaline phosphatase Radio: Osteolysis of proximal tibia, scoliosis generalised osteoporosis Radio: Osteolysis of proximal tibia, scoliosis generalised osteoporosis Sonography : (L) Parathyroid tumor 26x12mm, Sonography : (L) Parathyroid tumor 26x12mm, (R) Renal calculus 7mm Clinical diagnosis : Metastatic Carcinoma !? Clinical diagnosis : Metastatic Carcinoma !? ucg 27 ucg 27

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

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

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

21. Vuõ Vaên K., 48y.o. 566BH/00, 26 / 09 / 00 - Surgery 10/00 566BH/00, 26 / 09 / 00 - Surgery 10/00 Past history : 4yrs Bone pain Past history : 4yrs Bone pain Clinics : Heigh loss 6cm, limb discrepancy. No palpable parathyroid T O Clinics : Heigh loss 6cm, limb discrepancy. No palpable parathyroid T O Lab. : Calcemia 5 mEq/l Lab. : Calcemia 5 mEq/l Radio: Generalised osteoporosis & osteolysis, Compressive Fx of vertebrae Radio: Generalised osteoporosis & osteolysis, Compressive Fx of vertebrae DEXA : O steoporosis, Tscore:-3.59 DEXA : O steoporosis, Tscore:-3.59 ucg 32

22. K, 48y.o, M, Subperiosteal & Subendosteal resorption of Ischium, Femur & Tibia   

23. K, Expansile loculated Brown Tumor of Metacarpals 2-5 Bone Scan: Hot spot of calvaria, mandible, ribs, femurs, tibias...     

24. VUÕ VAÊN KYÙ, 48y.o. Clinico-radiological diagnosis : Metastatic Ca. or Parathyroid tumor ? Clinico-radiological diagnosis : Metastatic Ca. or Parathyroid tumor ? Sonography, MRI :(L) Parathyroid T. Sonography, MRI :(L) Parathyroid T. Biopsy of foot lesions : Brown T O Biopsy of foot lesions : Brown T O Surgery 10 / 00 : Resection of Parathyroid Tumor. Surgery 10 / 00 : Resection of Parathyroid Tumor. ucg 36

25. MRI : Parathyroid Tumor of (L) inferior gland        

26. Moderate Cellular Atypia => Adenoma or Carcinoma ???  ADENOMA    

27. RESULTS OF TREATMENT Obvious amelioration of health Obvious amelioration of health Good appetite, sleep Good appetite, sleep n Dimunition of musculo-skeletal pain after 3mths No tetany nor muscular spasm No tetany nor muscular spasm n Paresthesia of distal limb persist for 6 mths ucg27 ucg27

28. Traàn Thò N., 34 y.o. 49 BH / 99, 8 / 1 / 98 - Surgery 12 / 98 49 BH / 99, 8 / 1 / 98 - Surgery 12 / 98 1 yr : knee pain * 7 mth : clavicle fx. 1 yr : knee pain * 7 mth : clavicle fx. 5 mth : fatigue, back pain -> arthralgia 5 mth : fatigue, back pain -> arthralgia CLINIC : heigh loss 5 cm - kyphosis CLINIC : heigh loss 5 cm - kyphosis limb weakness - body contraction limb weakness - body contraction No palpable parathyroid tumor ucg 8

29. Fatigue, Heigh loss, Scoliosis

30. Traàn Thò N., 34 y.o. n Radio. : Osteoporosis, renal calculus n Sonography : 3st time: No parathyroid tumor ? 4 th time : Parathyroid tumor (+) n MRI : No parathyroid tumor (2). PT (+) 3 rd time n LAB. : Hypercalcemia 6,8 mEq / l n Testing Treatment : good response with Miacalcic + CaC + Vit AD ucg 10 ucg 10

31. RADIOGRAPHY-Generalised Osteoporosis, Subperiosteal Osteolysis 3 rd MRI - Parathyroid Tumor at the (L) inferior gland 

32. Histopathology : Parathyroid T. with mild cellular atypia Histopathology : Parathyroid T. with mild cellular atypia   

33. 3 yrs post-op Good Response with treatment

34. RESULTS OF TREATMENT n Aspects of osteoporosis & osteolysis do not change on radiography for 9 mths though patient feel less painful after 3 mths. Osteoporosis aspects will be improved clearly 1 yr later. Osteoporosis aspects will be improved clearly 1 yr later. n “Brown tumor” : reactive osteoslerosis 2 mths post-op.; cortical reconstruction 6 mths post-op. ucg34 ucg34

35. RESULTS OF TREATMENT Stress / pathologic fractures : callus seen at 3 mths post-op. with less or no pain. Stress / pathologic fractures : callus seen at 3 mths post-op. with less or no pain. Bone healing with osteosclerosis attain at 2-3 yrs later. Bone healing with osteosclerosis attain at 2-3 yrs later. ucg35 ucg35

36. Nguyen T. K. Đ., 43 y.o. 77 BH / 99, 8 / 1 / 99 - Surgery 3 / 99 77 BH / 99, 8 / 1 / 99 - Surgery 3 / 99 Past history : Renal calculi Past history : Renal calculi 3 mth : MVA -> bone Fx ? -> Cast 3 mth : MVA -> bone Fx ? -> Cast 1,5 mth : ablation of cast -> T O -> CTO 1,5 mth : ablation of cast -> T O -> CTO Clinics : (R) thyroid tumor 2 cm Clinics : (R) thyroid tumor 2 cm Radio: Osteolysis of (L) tibia,(R) femur (L) 4th rib -->Metastatic thyroid Ca. ? Radio: Osteolysis of (L) tibia,(R) femur (L) 4th rib -->Metastatic thyroid Ca. ? ucg 15 ucg 15

37. Nguyen T. K. Đ., 43 y.o. 8/ 1/ 99 : biopsy of Tibial T. - 376 YK -> suggestion of hyperparathyroidism 8/ 1/ 99 : biopsy of Tibial T. - 376 YK -> suggestion of hyperparathyroidism 21/1/99 : tumor curettage + I.M. nailing + bone graft 21/1/99 : tumor curettage + I.M. nailing + bone graft Same microscopic features -737 YK Same microscopic features -737 YK 25/3/99 : Parathyroid tumor resection, 3cm 25/3/99 : Parathyroid tumor resection, 3cm Patho.2321 YK: Parathyroid adenoma Patho.2321 YK: Parathyroid adenoma ucg 16 ucg 16

38. Ñ, 43 y.o., F, Parathyroid Adenoma 

39. D., 43 y.o., F, “Brown Tumor” of Tibia of Tibia Parathyroid Adenoma chief cell type

40. “Brown tumor” at (L) tibia    Stress Fracture healing  

41. Nguyen Van T., 56 y.o. 130 BH/08: 27/02 – 06/03/08 n n Bone mass with osteoporosis / osteolysis / multiple fractures n n ULTRASOUND: bilateral nodules, (L) thyroid cyst. Parathyroid Tumor (-). n n T-score: -3,88 n n PTH    699,4 pg/mL (N: 16-65pg/mL)  (L) Thyroid Cyst? => Parathyroid Adenoma!.

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

43. Nguyen Van T., 56 y.o. 3 mths pre-op. 2 yrs post-op.    Osteolysis (brown Tumor) of lateral malleolus Healing of bone lesion

45. HYPERPARATHYROIDISM n Very rare, 25 - 56 y.o., 8F / 2M during 23 yrs n Due to PARATHYROID TUMORS n Very late, all presented bone lesions n CLINICO - RADIO. : osteoporosis, osteolysis, fracture, fatigue, heigh loss, kidney stone, pseudotumor of bone ( Brown T O ) Parathyroid tumor : ± Parathyroid tumor : ±

46. PARATHYROID TUMOR n Ultrasound, MRI, Surgical Pathology (+) n Adenoma, good prognosis Carcinoma : very rare, based on invasion, distant metastasis ucg 47

47. PARATHYROID ADENOMA n Management : tumor resection + appropiate pre. & post-op. medication. Results of treatment : Results of treatment : * General status : good * Musculo-skeletal Symptoms : early improved Bone lesions seen on radiography : lately improved, need 1-2 yrs. Bone lesions seen on radiography : lately improved, need 1-2 yrs. Very difficult to manage in many cases! HOW TO DETECT & DIAGNOSE EARLY !!!

48. THANKS !