Hyperparathyroidism with bone tumor-like presentation, approach for diagnosis and surgical intervention

This work aims to find out a clinical approach for diagnosis of cases with hyperparathyroidism presented with bone tumor like condition as first and main presentation in order to differentiate primary bone tumors or secondary bone metastases from different types of hyperparathyroidism and to clear out the indications and type of surgery in such cases.

It is a prospective case series study done in the National Cancer Institute from April 2000 to May 2009. During this period we followed 45 cases of hyperparathyroidism (HPT) presented with a main complaint of bone tumor-like lesion. We started by clinical evaluation, laboratory investigationsincluding: Parathormone hormone, total and ionic calcium, renal function tests, alkaline phosphatase, 24h urine calcium, C-AMP in urine or inappropriate parathormne like peptide if needed and radiological investigations for preoperative localization including neck ultrasound, Tc99m Sestamibi scan, C-T neck and superior mediastinum or M.R.I. Intraoperative ultrasound was used in some cases. Postoperative bone desimetry and plain-X ray to follow bone mineral deposition were done.

Preoperative diagnosis was: 80% cases of primary hyperparathyroidism (pHPT), 15.5% cases of secondary hyperparathyroidism (sHPT), 4.5% tertiary hyperparathyroidism (tHPT), benign adenoma in 73.3%, diffuse hyperplasia in 8.8% and one case of parathyroid carcinoma. Neck ultrasound localized 29/38 adenoma (sensitivity = 73.3%), sestamibi localized 23/38 including another 2 cases of diffuse hyperplasia not detected by ultrasound (sensitivity = 63.8%), C-T scan detected adenoma in upper mediastinum. Total preoperative localization was 84.2%. We used unilateral exploration in 27 cases, and bilateral in 11 cases. Intraoperative ultrasound was useful in detection of 2 additional cases in the thyroid lobe tissue. Intraoperative parathormone hormone after 10 minutes dropped in all of cases. Recurrence of the disease occurred in 2 cases during follow-up (5.2%). Postoperative sever hypocalcemia occurred in 4 cases necessitating longer hospitalization and longer period of oral calcium. Healing in cortical bone was faster than cancellous bone.

Hyperparathyroidism should be suspected in all cases with bone tumor-like presentation or even in earlier disease complain of bony or muscle aches. Intact P.T.H and calcium (total &ionic), renal functions, 24 hours urine calcium, neck ultrasonography, and Tc 99m pertechnitate/Tc99m sestsmibi subtraction scan can establish the diagnosis. Surgical treatment with unilateral approach or bilateral when indicated with intraoperative ultrasound localization, frozen section examination and assessment of intraoperative 10 minutes-P.T.H is very successful with minimal rate of recurrence and complications.

Hyperparathyroidism - Bone tumor-like presentation - Diagnosis - Surgical approach.