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Brown tumors due to secondary hyperparathyroidism detected by 11C-choline PET/CT
Detección de tumores pardos por hiperparatiroidismo secundario mediante PET/TC con 11C-colina
J.R. García
, F.J. Alvarez Moro, P. Bassa, M. Soler, E. Llinares, E. Riera
Corresponding author
CETIR-ERESA, Esplugues de Llobregat, Barcelona, Spain
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Patrón metabólico caracterizado por aumento difuso de la captación en el esqueleto axial y ausencia de representación de ambas siluetas renales, sugestivo de hiperparatiroidismo de origen renal. Como hallazgo extra-óseo se observa captación en área miocárdica. Se distinguen imágenes activas, focales, en tercio distal de clavícula izquierda y epífisis proximal de la tibia izquierda, que podrían corresponder con lesiones metastásicas, pero en localizaciones poco habituales. Aspecto gammagráfico de ambas coxofemorales sugestivo de osteonecrosis, con predominio de la isquemia en la derecha y más evolucionado en la izquierda, a correlacionar con RM. Signos de osteoartropatía dorsales bajos y, principalmente, lumbares bajos, del maléolo tibial y tarso izquierdo, rizartrosis izquierda y sobrecarga articular en la rodilla y en el maléolo tibial derechos.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.R. García, F.J. Alvarez Moro, P. Bassa, M. Soler, E. Llinares, E. 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Also, somatostatin receptor (SSTR) expressing metastatic disease was found in left cervical lymph nodes <span class="elsevierStyleBold">(</span>e, f; <span class="elsevierStyleItalic">white arrows</span>, g; <span class="elsevierStyleItalic">bold white arrow</span>) and multiple skeletal sites (g; white arrows).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Mukherjee, V. Singh Dhull, S. Arora, C. Bal, R. Kumar" "autores" => array:5 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Mukherjee" ] 1 => array:2 [ "nombre" => "V." "apellidos" => "Singh Dhull" ] 2 => array:2 [ "nombre" => "S." "apellidos" => "Arora" ] 3 => array:2 [ "nombre" => "C." "apellidos" => "Bal" ] 4 => array:2 [ "nombre" => "R." "apellidos" => "Kumar" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2253808916000392?idApp=UINPBA00004N" "url" => "/22538089/0000003500000003/v2_201703300105/S2253808916000392/v2_201703300105/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S2253808916000380" "issn" => "22538089" "doi" => "10.1016/j.remnie.2015.06.001" "estado" => "S300" "fechaPublicacion" => "2016-05-01" "aid" => "714" "copyright" => "Elsevier España, S.L.U. and SEMNIM" "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Rev Esp Med Nucl Imagen Mol. 2016;35:207-8" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 9 "PDF" => 9 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Interesting image</span>" "titulo" => "Comparison of <span class="elsevierStyleSup">18</span>F FDOPA PET, DSC-MRI and spectroscopy in a patient with brain metastatic lesions from lung cancer" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "207" "paginaFinal" => "208" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Comparación de los <span class="elsevierStyleSup">18</span>F FDOPA PET, DSC-MRI y espectroscopia en un paciente con lesiones metastásicas cerebrales de cáncer de pulmón" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:6 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1377 "Ancho" => 1700 "Tamanyo" => 342480 ] ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. 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Riera" "autores" => array:6 [ 0 => array:4 [ "nombre" => "J.R." "apellidos" => "García" "email" => array:1 [ 0 => "jrgarcia@cetir.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "F.J." "apellidos" => "Alvarez Moro" ] 2 => array:2 [ "nombre" => "P." "apellidos" => "Bassa" ] 3 => array:2 [ "nombre" => "M." "apellidos" => "Soler" ] 4 => array:2 [ "nombre" => "E." "apellidos" => "Llinares" ] 5 => array:2 [ "nombre" => "E." "apellidos" => "Riera" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "CETIR-ERESA, Esplugues de Llobregat, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Detección de tumores pardos por hiperparatiroidismo secundario mediante PET/TC con <span class="elsevierStyleSup">11</span>C-colina" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1857 "Ancho" => 2502 "Tamanyo" => 230834 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">11</span>C-Choline PET/CT. Focal tracer uptake is seen in parathyroid inferior nodules (right: SUVmax 5.4; left: SUVmax 3.6) due to parathyroid hyperplasia secondary to chronic kidney disease, which was confirmed surgically. (A, B) Irregular <span class="elsevierStyleSup">11</span>C-Choline uptake in both prostate lobules, with moderate intensity,(right: SUV 2.4; left: SUV 2.9), which reflected primary tumor burden diagnosed in this patient. Low <span class="elsevierStyleSup">11</span>C-Choline uptake, less than the bony lesions in left bone collar (C) and tibia (D), which corresponded with a lytic lesion on CT on distal end of left bone collar, with thickening and ill-defined cortical margins (curvilineal reconstruction – C), as well as another lytic lesion with outer cortical thickening and sclerosis in lateral aspect of proximal epiphysis of tibia (reconstructed coronal slice – D).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 76-year-old patient with a long term gouty nephropathy is reported. Patient presented with prostatic syndrome and prostate carcinoma was diagnosed (Gleason score 3<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>4; PSA 11<span class="elsevierStyleHsp" style=""></span>ng/ml; T1c stage). For staging purpose, abdominal CT and bone scan were performed. CT was uneventful and bone scan showed a metabolic systemic pattern with a focal uptake in distal end of left collar bone and proximal end of left tibia (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Given these non-specific lesions in bone scan, a PET/CT with <span class="elsevierStyleSup">11</span>C-Choline was performed, which showed increase uptake in both prostate lobes related to primary disease, and no hypermetabolic foci were detected in lymphatic territories. Bone lesions previously described showed a less phospholypidic than phosphonate uptake, and the CT scan depicted lytic component. Bilateral focal <span class="elsevierStyleSup">11</span>C-Choline uptake was shown in lower parathyroid gland (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">In light of these findings, patient underwent biochemical study, and an inhibited PTH was revealed, with normal calcium levels. Parathyroid adenoma and hyperplasia are the main cause of primary hyperparathyroidism, represented by increase in PTH and hypercalcemia. Secondary hyperparathyroidism represents a PTH oversecretion due to hypocalcemia secondary to increased renal excretion of calcium in patients with chronic renal failure. In very late stages, these patients may show hypercalcemia, known as tertiary hyperparathyroidism.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Taking into account the patient history, <span class="elsevierStyleSup">11</span>C-Choline PET/CT and biochemical findings, a subtotal parathyroidectomy was performed, which showed inferior bilateral parathyroid hyperplasia.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Therefore, it is suggested that this patient is bearing a prostate carcinoma stage T1cN0M0 along with bone lesions in left collar bone and tibia, most likely related to brown tumors.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Renal osteodystrophy accounts for bone metabolic changes related to chronic kidney disease, and its scintigraphy pattern is variable. Most common finding is a general increased tracer uptake in bone, secondary to high bone turnover, due to secondary hyperparathyroidism (blood phosphate increase and loss of Vitamin D, which induces hypocalcemia and increase in PTH production). There may be also findings related to osteomalacia and an increase in subperiosteal osseous formation-process in long bones. In advanced cases, a generalized decrease in bone uptake may appear, secondary to bone loss.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Focal lesions may also appear, besides diffuse bone changes, which are known as brown tumors or osteitis fibrosa cystica, thus representing a cellular reparative process rather than a malignant disease. Hypocalcemia in patients with chronic kidney disease results in skeletal calcium recruitment, thus increasing bone osteoclastic turnover. In these sites where bone loss is especially dramatic, normal medullar content may be replaced by granulomatous reparative tissue, with hemorrhagic patches and proliferative fibrous tissue, which all result in brown tumors. These lesions are lytic on CT imaging and show avid tracer uptake in bone scan.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In our case, patient was treated with radiotherapy and hormonotherapy (6 months) for his prostate cancer and remains free of disease 1 year afterwards, with PSA levels within normal range.</p><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflicts of interest</span><p id="par0270" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: García JR, Alvarez Moro FJ, Bassa P, Soler M, Llinares E, Riera E. Detección de tumores pardos por hiperparatiroidismo secundario mediante PET/TC con <span class="elsevierStyleSup">11</span>C-colina. Rev Esp Med Nucl Imagen Mol. 2016;35:209–210.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1668 "Ancho" => 1013 "Tamanyo" => 53563 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Bone scan. A metabolic pattern is shown, characterized by diffuse increase of tracer in axial skeleton and faint renal uptake (“superscan” pattern suggested by a hyperparathyroidism of renal origin). Moreover, unexpected tracer uptake is seen in myocardial region. There are also focal active spots in distal end of left bone collar and proximal epiphysis of left tibia, which could be attributed to bone malignancy in uncommon sites. Scintigraphic appearance of bilateral hip is suggestive of proximal femur osteonecrosis with predominant ischemia in right femur, and more advanced stage in left femur. To be correlated with MRI findings. Osteoarthritic changes are seen in thoracic and lumbar spine, in left ankle and tarsus, left trapezoid-metacarpal osteoarthritis, joint overload in right knee and ankle.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1857 "Ancho" => 2502 "Tamanyo" => 230834 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">11</span>C-Choline PET/CT. Focal tracer uptake is seen in parathyroid inferior nodules (right: SUVmax 5.4; left: SUVmax 3.6) due to parathyroid hyperplasia secondary to chronic kidney disease, which was confirmed surgically. (A, B) Irregular <span class="elsevierStyleSup">11</span>C-Choline uptake in both prostate lobules, with moderate intensity,(right: SUV 2.4; left: SUV 2.9), which reflected primary tumor burden diagnosed in this patient. Low <span class="elsevierStyleSup">11</span>C-Choline uptake, less than the bony lesions in left bone collar (C) and tibia (D), which corresponded with a lytic lesion on CT on distal end of left bone collar, with thickening and ill-defined cortical margins (curvilineal reconstruction – C), as well as another lytic lesion with outer cortical thickening and sclerosis in lateral aspect of proximal epiphysis of tibia (reconstructed coronal slice – D).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:3 [ 0 => array:3 [ "identificador" => "bib0020" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Differential diagnosis between secondary and tertiary hyperparathyroidism in a case of a giant-cell and brown tumor containing mass. Findings by <span class="elsevierStyleSup">99m</span>Tc-MDP, <span class="elsevierStyleSup">18</span>F-FDG PET/CT and <span class="elsevierStyleSup">99m</span>Tc-MIBI scans" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "G.K. Gedik" 1 => "O. Ata" 2 => "P. Karabagli" 3 => "O. 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