Brown Tumor Research Articles

Severe Refractory Hypocalcemia After Administering Zoledronic Acid for Osteoporotic Fracture in Primary Hyperparathyroidism That Is Complicated Into Hungry Bone Syndrome: A Case Report

Zoledronic acid is a very effective (IV) amino bisphosphonate which is indicated in osteoporosis, hypercalcemia of malignancy, multiple myeloma, Paget’s disease, and bone metastases from solid tumors. Bisphosphonate inhibits bone resorption through actions on osteoclast activity resulting in increasing bone density. Unfortunately, there are side effects associated with zoledronic acid one of those is mild to moderate hypocalcemia. Hungry Bone Syndrome (HBS) is defined as a severe drop in calcium levels less than 2.1 mmol/L and/or prolonged hypocalcemia for more than 4 days post parathyroidectomy. Most seen in patients’ who have secondary hyperparathyroidism compared to primary hyperparathyroidism. The sudden drop of parathyroid (PTH) levels post parathyroid resection after a prolonged duration of high PTH levels causes net calcium to move into the bone, this is the most proposed hypothesis. The authors report a case of a 32 years old female known case of severe osteoporosis presented to the emergency department complaining of left hip pain after a short height fall admitted as a case of pathological fracture. Furthermore, upon admission was vitally stable although on examination the patient had left side hip pain and tenderness otherwise unremarkable. Initial lab investigation showed a calcium level of 2.57 mmol/L and PTH level 37 pmol/L otherwise electrolytes and full blood count were unremarkable. Radiological investigations were done, and an X-ray has shown a left hip fracture where the patient underwent an operating room for fixation. In addition, a 99mTc-HDP bone scan revealed hyperparathyroidism and brown tumor. 99m Tc SESTA-MIBI whole body scan suggested metabolic bone disease. Furthermore, the parathyroid showed suggested typical parathyroid adenoma below and lateral to the lower pole of the left thyroid lobe. The ultrasound of the thyroid showing a well-defined hypoechoic nodule 2.5x1.15 cm with significant hypervascularity is seen, which is most likely to be enlarged left parathyroid gland. Thus, diagnosis of primary hyperparathyroidism has been reached with parathyroid adenoma which was resected during a hospital stay. The patient received pre-op zoledronic acid as a treatment for osteoporosis prior to the hip operation. After the parathyroid adenoma resection, the patient had a sudden drop of PTH and developed hypocalcemia which was 1.1 mmol/L. Thus, the complication of post operated parathyroid adenoma of HBS diagnosis has been made. Interestingly the patient needed to increase the length of stay of the hospital due to refractory hypocalcemia where the patient has been receiving IV calcium and vitamin D supplementation which hadn’t improved until a month of IV calcium gluconate. Although, the patient didn’t develop any signs or symptoms of hypocalcemia.

Hyperparathyroidism-Jaw Tumor Syndrome in a Patient With Colon Cancer: A Case Report

Abstract Background: Hyperparathyroidism-jaw tumor syndrome (HPT-JT) is a rare autosomal dominant disease, caused by mutations in the CDC73 gene, characterized by parathyroid tumors in association with fibro-osseous lesions of the mandible or maxilla. The occurrence of renal cysts or tumors, uterine and thyroid tumors has been reported. The association with other neoplastic lesions has been described, but its meaning and frequency are not well established. Clinical Case: A 48-year-old Roma woman was admitted to our hospital due to severe abdominal pain and constipation. She had a past history of kidney stones with several episodes of acute renal colic and had been recently diagnosed with colon cancer. Her family history was positive for colon cancer. Disease staging suggested the presence of liver metastases and multiple lytic lesions of the axial skeleton, pelvis and femurs. Laboratory investigation disclosed high calcium levels (15 mg/dL) and cancer associated hypercalcemia was suspected. However, PTH was markedly elevated (2979 pg/mL), in favor of a parathormone dependent cause. Further imaging procedures showed a heterogeneous mass, posterior to the right thyroid lobe and bone lesions on the left mandible, likely to correspond to brown tumors. Once the hypercalcemia was controlled, she was submitted to parathyroidectomy and right thyroid lobectomy plus sigmoidectomy and liver biopsy. The histology revealed an atypical parathyroid adenoma with 3,5 cm and papillary thyroid cancer with 1,2 cm, as well as colon adenocarcinoma metastatic to the liver. Postoperatively, the patient developed a hungry bone syndrome needing adequate treatment. Two months after surgery, the patient initiated chemotherapy for colon cancer. Screening for germline mutations in the CDC73 gene (formerly HRPT2) was positive for a deletion (c.765_766delTG/p.Val256LysX10). Conclusions: Hypercalcemia in a patient with malignant disease may be independent of malignancy. In the patient presented herein her past history of kidney stones and the involvement of the mandible were highly suggestive of HPT-JT. Missing the diagnosis would negatively impact in the patient′s prognosis and in the management of her family. Further clinical and genetic studies are ongoing trying to clarify whether the patient has two inherited conditions or a phenotype of HPT-JT including colon cancer.

Osteitis Fibrosa Cystica A Rare Presentation of Primary Hyperparathyroidism

Introduction: Osteitis fibrosa cystica (OFC) is the most serious bone involvement of primary hyperparathyroidism (PHPT), it is characterized by subperiosteal resorption, lytic lesions and the appearance of brown tumors; this is why, in some cases, this condition can easily be mistaken for a malignant neoplasm. Its prevalence in developed countries is only 5%.Clinical Case: We present a 58-year-old woman, with no relevant personal history, who came to the emergency room with pain in her right shoulder after an accidental fall on the bus. The humerus radiograph shows a pathological fracture of the right humerus, with significant osteopenia. In the emergency analysis, serum Calcium 13.3 mg / d), Ionic Calcium 7.03 mg / dL, Phosphorus 2.4 mg / dL, Alkaline Phosphatase 248 U / L and normal kidney function stand out. With a diagnosis of severe hypercalcemia, treatment was started in the emergency room with serum therapy (1000 ml of 0.9% physiological saline in 4 hours) and intravenous diuretic treatment (furosemide 40mg) with a decrease in calcemia to 12.8mg / dL. Later, she was admitted to the Internal Medicine hospital ward to perform a differential diagnosis of hypercalcemia secondary to a primary tumor, Multiple Myeloma or Primary Hyperparathyroidism. The study findings are: Calcium metabolism: PTH 660 pg / ml (12 - 65), 25 Hydroxyvitamin D: 14.00. Thyroid ultrasound: Posterocaudal to right thyroid lobe, an area of ​​echogenicity slightly lower than the thyroid is identified, of dimensions not estimated by endothoracic component, which could correspond to a parathyroid adenoma. Body CT: Neck: Heterogeneous nodule dependent on the posterior region of the right thyroid nodule with endothoracic extension. Skeleton: Lytic lesions with a tumor aspect in the humerus, right scapula and bilateral seventh rib and right pubic branch. Skull: Diffuse increase in bone density of the calvaria, showing multiple punctate lytic lesions with a permeative appearance. Bone densitometry: Femur neck: - <1.5, Lumbar spine: - <3.0 With the diagnosis of PHPT causing osteitis fibrosa cystica, surgical intervention was decided. Under general anesthesia, a selective right approach was performed, finding a large parathyroid adenoma weighing 17 grams. PTH fell to 36 pg / ml after surgery. At 9 months after surgery, the patient presented calcium levels of 9 mg / dl and PTH 146 pg / ml with clear radiological improvement.Discussion: Osteitis fibrosa cystica is rare in our environment, it is often confused with other neoplasms. After parathyroidectomy, patients with PHPT have a marked and sustained recovery from OFC, although in some cases this recovery can only be achieved after several years. We consider this case of interest, since it illustrates the importance of evaluating the study of phospho-calcium metabolism and parathyroid function in all patients with bone lesions to rule out Primary Hyperparathyroidism with OFC.

Experience With Anti-Sclerostin Antibody for Osteoporosis Patient With End-Stage Renal Disease on Hemodialysis

Background: Romosozumab is a sclerostin inhibitor indicated for treatment of postmenopausal osteoporosis. Sclerostin inhibits Wnt/Beta-catenin signaling pathway. When sclerostin is inhibited, stimulation of this pathway leads to increased bone formation and production of osteoprotegerin, which also decreases bone resorption. Patients with chronic kidney disease (CKD) demonstrate increased levels of sclerostin that negatively correlates with the rate of bone formation; however, data is lacking for use of romosozumab in this patient population. The report herein details the experience of use of romosozumab in a patient with end-stage renal disease (ESRD) on hemodialysis (HD). Clinical Case: A 37-year-old old African American male was referred after multiple rib fractures and severe non-traumatic T8 compression fracture with nerve compression. His past medical history includes lupus nephritis and cerebritis, ESRD on HD since age 22 status post (s/p) failed renal transplant, and tertiary hyperparathyroidism complicated with fracture in iliac brown tumor and mediastinal parathyromatosis s/p three parathyroid surgeries. Bone mineral density by DXA (g/cm2, Z-score) were as follows: lumbar spine (0.700, -4.0) femoral neck (0.676, -3.8), total hip (0.628,-4.0), 1/3 radius(0.443,-6.2). No prior exposure to antiresorptive or osteoanabolic agents. Pertinent labs included serum calcium 8.5 mg/dL (nl 8.9–10.3 mg/dl), albumin 4.2 g/dL, alkaline phosphatase 319 U/L (nl 38–126), Phosphorus 3.1 mg/dL (2.4–4.7), Creatinine 5.62 mg/dl, 25-OH Vitamin D 31 ng/mL (nl 25 - 80), intact parathyroid hormone 17.9 pmol/L (nl 1.6–6.9). Patient was in excruciating pain and not a surgical candidate due to poor bone quality. Osteoanabolic therapy was recommended given the severity of osteoporosis; however, teriparatide and abaloparaitde were contraindicated given comorbidities. The patient was offered off-label use of Romosozumab with clear understanding that the drug is not approved for this indication and safety/efficacy data in ESRD is not known. The boxed warning regarding increased risk of stroke, myocardial infarction and death were discussed and patient was willing to proceed. Repeat DXA after eleven monthly doses of Romosozumab resulted in a remarkable improvement in bone mineral density at all sites: lumbar spine (+47%), femoral neck (+41%), total hip (+28%), 1/3 radius (+20%). Patient tolerated medication with no side effects or fractures. Serum calcium was monitored prior to initiation and before every dose. No doses were held due to abnormal laboratory values or side effects. Conclusion: This case report summarizes successful experience with the use of Romosozumab in one patient with ESRD on HD with favorable outcomes.

Atypical Parathyroid Adenoma in a Young Man

Patient is a 38-year-old man who developed sudden onset of pain in the upper left arm while carrying a case of water. The pain recurred periodically over the next few months. He presented to the emergency department where imaging showed a pathologic fracture in the proximal left humerus through a lytic lesion. Laboratory testing showed: calcium 13.8 mg/dL (8.5–10.1 mg/dL), 25-OH vitamin D 8 ng/mL (31–100 ng/mL), parathyroid hormone 1583.1 pg/mL (18.5–88 pg/mL). Neck ultrasound showed a complex nodule in the left neck measuring 4.2 x 1.7 x 2.5 cm. Subsequent biopsy of the left arm lesion showed a Brown tumor. The patient was referred to endocrinology. There was concern for parathyroid carcinoma given the elevated parathyroid hormone and large neck lesion. Technetium-99m sestamibi scan showed a 4.1 x 2.6 x 2.5 cm mass posterior to the left thyroid lobe. He subsequently underwent left hemithyroidectomy and parathyroidectomy. Pathology revealed a 3.1 cm parathyroid mass with scattered fibrous bands, foci of prominent nucleoli and foci of sheet-like trabecular and spindled architecture. It was without necrosis, lymphovascular invasion, perineural invasion, increased mitotic activity, atypical mitoses or invasion into adjacent structures. Thus, it was classified as an atypical parathyroid adenoma.Primary hyperparathyroidism is the third most common endocrine disorder, but fewer than 2% occur as a result of an atypical parathyroid adenoma. Patients with an atypical parathyroid adenoma tend to have a more dramatic clinical presentation compared to those with classic adenoma. We see higher calcium and parathyroid hormone levels. Atypical parathyroid adenomas are classified as such due to other features which place the lesion at a higher risk for malignant behavior including higher mitotic activity, adherence to adjacent structures, banding fibrosis and a growth pattern that is either solid or trabecular. In contrast to parathyroid carcinoma, atypical parathyroid adenomas do not show invasion into the surrounding tissues or lymphatic/vascular vessels, and there should be no evidence of metastatic disease. The exact definition of an atypical parathyroid adenoma varies among institutions, and recognition of the defining features (or lack thereof) necessitates an experienced endocrine pathologist.Due to their uncertain malignant potential, patients with an atypical parathyroid adenoma should undergo routine surveillance for recurrence. Routine follow-up of calcium, parathyroid hormone and imaging is indicated to detect for recurrence. A CDC73 germline mutation is associated with recurrence compared to CDC73-negative patients. Parafibromin expression is also thought to play a role although studies so far have had discrepant results.

Osteitis Fibrosa Cystica: An Unusual but Still Prevalent Manifestation of Uncontrolled Secondary Hyperparathyroidism

Abstract Background: Osteitis fibrosa cystica is an uncommon complication of untreated secondary hyperparathyroidism in patients with end-stage renal disease. The characteristic bony lesions that are seen in this condition very rarely can regress after medical treatment or parathyroidectomy. Clinical Case: A 65-year-old male with PMH of Systemic Lupus Erythematous (SLE) resulting in End-Stage Renal Disease (ESRD) on peritoneal dialysis (PD) and HTN, presented to his primary care physician for evaluation of a painful, enlarging lesion in his left forearm. The patient reported no history of trauma and denied having systemic symptoms. An X-Ray of his left forearm showed a lytic lesion within the proximal neck of the ulna, with erosion of the adjacent cortex. CT of the forearm showed a very vascular soft tissue mass causing significant erosive changes of the anterior cortex in the proximal ulna. Due to the characteristics of the lesion, an underlying malignancy was suspected as a possible diagnosis. The patient had a whole-body PET CT which showed multiple scattered hypermetabolic lytic osseous lesions throughout the axial and appendicular skeleton, including a large left proximal ulnar lesion. The patient had a bone biopsy from the lesion in his left ulna which showed a giant cell proliferation in a background of fibrosis and hemosiderin, suggestive of Osteitis Fibrosa Cystica (brown tumor of hyperparathyroidism). His laboratory workup around the time of the symptoms showed a normal serum calcium (9 mg/dl), associated with a high serum phosphorus (6.2 mg/dl), low vitamin D (20 ng/ml), and an elevated PTH (900 pg/ml). The patient was started on Cinacalcet, an increased dose of phosphate binders, as well as Calcitriol and the lesions and pain disappeared. Follow up lab work showed a normal Vitamin D (34 mg/dl), normal Phosphorus (4 mg/dl), and a PTH of 199 mg/dl, with a normal serum Calcium. A surveillance PET was performed 6 months after the initial one when the lesions clinically had disappeared and it showed again the presence of the bony lesions described prior, including the one in the left ulna, but with decreased FDG uptake, as well as new lesions in the spine. To date, the patient is asymptomatic and has not noted any new painful lesions. Conclusions: Osteitis fibrosa cystica remains a rare manifestation of secondary hyperparathyroidism, which may lead to an initial impression of malignancy. This patient exhibited clinical resolution of the painful symptoms associated with osteitis fibrosa cystica following medical management, though the lytic lesions involving the axial and appendicular skeleton persisted on surveillance imaging. This case serves as a reminder of the severe manifestations of a skeletal disease that has become rare given advances in early detection of and appropriate medical management of hyperparathyroidism.

Brown Tumor and Hyperparathyroidism in Orthopaedic Surgery

Brown Tumor and Hyperparathyroidism in Orthopaedic Surgery

Multiple brown tumors: A severe bone complication of pseudohypoparathyroidism after 15 years of loss of follow-up

Multiple brown tumors: A severe bone complication of pseudohypoparathyroidism after 15 years of loss of follow-up

POS-090 PRIMARY HYPERPARATYHROIDISM: A NEPHROLOGIST EXPERIENCE

Primary hyperparathyroidism (PHPT) is a common endocrine disorder frequently encountered in everyday practice. It classically presents with hypercalcemia which is the hallmark of the disease in association with inappropriately normal to high levels of PTH . The clinical presentation may vary from asymptomatic to symptomatic disease with eventual complications, for instance skeletal and renal abnormalities. It may be due to a single benign parathyroid adenoma which is by far the most common cause or a multiglandular disease in the familial forms Herein is a retrospective and descriptive single-center study of PHPT observed among patients between 2010 and 2020 realized in our department of nephrology in Monastir Tunisia. 10 patients were gathered. The mean age was 58.5 years ranging from 27 to 87 years . The sex ratio was1 :1. Hypertension was found in 5 patients (50 %) : 3 females and 2 males. 1 patient was found to have diabetes. Lithiasis occured in 3 patients all of whom were women and nephrocalcinosis occured in 2 patients. There were no vascular calcifications nor pain in any patient. The average hemoglobin was 9.2 g/dl ranging from 8 to 11.3 g/dl. All patients had hypercalcemia with a mean of 3.09 mmol/l. 5 patients had hypophosphatemia (50 %). PAL was available in 5 patients all of whom had elevated levels with a mean of 190.8 UI/ml. The mean creatinine level was 196.2 umol/l. Cervical ultrasound was performed in all patients and came back normal in 6 patients (60%). In the remaining patients, it has shown bilateral or unilateral lobules. Scintigraphy was also performed in all patients and findings were consistent with those found in the 4 patients with ultrasound abnormalities but has shown anomaly in 4 of the 6 patients (66%) in whom ultrasound came back normal. One patient had developed a brown tumor. Total parathyroidectomy was performed in 6 patients and partial parathyroidectomy in 2 patients. In the post-operative follow-up, all of the patients have normalized their calcemia levels , 5 patients have normalized their kidney function (50%) and the diagnosis of acute kidney injury secondary to hypercalcemia was retained. PHPT affects women 3 to 4 times more than men but in our study they were similar. Hypercalcemia was the most important biological sign.

Brown Tumor of Tertiary Hyperparathyroidism in Chronic Hemodialysis: A Case Report

Brown Tumor of Tertiary Hyperparathyroidism in Chronic Hemodialysis: A Case Report

Cherubism - Clinical case report and narrative review

Cherubism is described as a rare and benign hereditary bone disease, characterized by a bilateral volumetric increase in the maxillary bones, with a greater predilection for males in childhood. Clinically, it presents as a volumetric enlargement of the mandible and, maxilla, which is generally painless, firm on palpation and varies in relation to size and extension. Its differential diagnosis is the Brown Tumor of Hyperparathyroidism and the Central Lesion of Giant Cells. The diagnosis is based on the assessment of clinical characteristics together with complementary exams. The objective of this study was to carry out a brief review of the literature and report a clinical case of this pathology in a 9-year-old child with a family history of cherubism, assessed through imaging, histopathological and karyotype exams, which continues to be assisted by the oral and maxilofacial surgery team of the Faculdade de Odontologia de Araçatuba - FOA Unesp since the treatment of the cherubism still does not have a definitive protocol.

Primary Hyperparathyroidism with Multiple Fractures and Brown Tumors in a 14-year-old Girl: Case Report &amp; Review of Literature

Primary hyperparathyroidism (PHPT) presenting as pathological fractures with brown tumors is very rare in children. The rarity and variable presentation of PHPT can make its diagnosis a challenge – especially in the developing countries where malnutrition may mask hypercalcemia. We report a case of a 14–year-old girl who presented with muscle pain, multiple fractures and bone pain. Laboratory tests revealed normocalcemia with vitamin D insufficiency. Subsequent biochemical, radiographic and scintigraphic findings were consistent with primary hyperparathyroidism due to a parathyroid adenoma. Tumor resection was done in a local hospital and histopathology confirmed parathyroid adenoma. Following parathyroidectomy, fractures were treated conservatively with supplementation of calcium and vitamin D. We found her quite capable of self-care and walking in good health at 1 year follow up. Though rare, PHPT-causing brown tumors related skeletal fractures is an important differential diagnosis in the evaluation of patients presenting with multiple foci of radiotracer uptake in bone scintigraphy.&#x0D; Bangladesh J. Nuclear Med. 22(2): 130-136, Jul 2019

Osteitis Fibrosis Cystica: Classical Case Report of an Uncommon Presentation in a Young Female.

Osteitis fibrosa cystica (OFC) is a skeletal disease related to long standing, end-stage hyperparathyroidism. However, nowadays hypercalcemia due to primary or secondary hyperparathyroidism can often be detected early by laboratory screening and imaging modalities; consequentially the frequency of osteitis fibrosa cystica has drastically declined. OFC, also termed as Brown tumor, can mimic primary bone tumors clinically, which often leads to misdiagnosis and inappropriate management. Moreover due to its rarity, it is usually not considered initially in the differential diagnosis of bony tumors. Case presentation: This is the case of a 19-year-old female, who presented with pain over the left ankle region for 3months. The biochemical screening revealed a picture consistent with primary hyperparathyroidism and the radiologically proven to be left inferior parathyroid adenoma. She underwent excision of the primary parathyroid adenoma, and gradual regression of symptoms was noted postoperatively. Osteitis fibrosa cystica is a rare manifestation of hyperparathtyroidism, which has become a forgotten entity lately due to early identification of hypercalcaemia by modern techniques. A delay in the diagnosis of parathyroid adenoma results in manifestations that can be avoided. The diagnosis of OFC requires a high degree of clinical suspicion. When hypersecretion of PTH is corrected, spontaneous regression of the lesion is expected.

Femoral nerve compression caused by a hibernoma in the right thigh: a case report and literature review

BackgroundA hibernoma, also known as a brown fat tumor, is a rare benign soft tissue tumor, which originates from brown adipose tissue remaining in the fetus after the gestational period. It is often detected in adult men, presenting as a painless slow-growing mass. Hibernomas of the thigh have been reported; however, motor and sensory disorders caused by the tumors compressing the femoral nerve have not been reported. We report a case of a histopathologically proven hibernoma that induced femoral mononeuropathy.Case presentationA 26-year-old man was admitted to the hospital due to a mass, approximately 11.0 × 9.0 × 4.0 cm in size, that had developed 5 years ago in the anterolateral aspect of the proximal thigh. Furthermore, he had a history of hypoesthesia 1 month prior to his admission. He had signs and symptoms of both a motor and sensory disorder, involving the anterior aspect of the right thigh and the medial aspect of the calf, along the distribution of the femoral nerve. During surgery, the femoral nerve was found to be compressed by the giant tumor. The resultant symptoms probably caused the patient to seek medical care. Marginal resection of the mass was performed by careful dissection, and the branches of the femoral nerve were spared. Histopathology examination showed findings suggestive of a hibernoma. At the 4-month follow-up, no femoral nerve compression was evident, and local tumor recurrence or metastasis was not found.ConclusionsAsymptomatic hibernomas do not require treatment; however, in cases of hibernomas with apparent symptoms, complete marginal surgical excision at an early stage is a treatment option because it is associated with a low risk of postoperative tumor recurrence.

Oral Kavitede Kitle Nedeni Olarak Brown Tümör

Oral Kavitede Kitle Nedeni Olarak Brown Tümör

Giant Cell Tumour of Clivus: A Rare Case Report

Giant Cell Tumours (GCT) of the skull is rare, being less than 0.05% of all skeletal tumours. They are usually located in the middle cranial fossa affecting the temporal, sphenoid, petrosal and occipital bone. Clival GCT is rarer and 15 cases are described in the literature. Authors report a case of a female patient aged 20 years, who complained of headache with decrease in vision of left eye. Neurological examination revealed left optic nerve palsy. Laboratory test of Vitamin B12, blood urea, Serum Creatinine, Serum Electrolytes were within normal range. Complete blood count showed mild anaemia. The serum calcium and parathyroid hormones were within normal range. Computed Tomography (CT) scan and Magnetic Resonance Imaging (MRI) were done, which demonstrated expansile destructive lytic lesion involving sphenoid bone and clivus, reaching upto sellar, parasellar regions, sphenoid sinus and left posterior ethmoid sinus, effacing left optic foramina and posteriorly effacing prepontine cistern. The left internal carotid artery was partially encased by the mass. The tumour was partially removed by endoscopic trans-nasal trans-sphenoidal approach. Histopathology confirmed it as a benign GCT. Surgical treatment of clival GCTs are fraught with complication because of its close proximity to vital structures. High vascularity, potential malignant behaviour, inaccessibility and very few published cases preclude a definite outcome of this lesion. Histopathology is necessary to differentiate various lytic lesion like chordoma, aneurysmal bone cyst, invasive pituitary adenoma, chondrosarcoma and brown tumour (parathyroidism).

Brown tumor of the mandible as an initial presentation of hyperparathyroidism

The paper presents a brown tumor case related to secondary hyperparathyroidism in an end stage kidney disease patient undergoing dialysis treatment. The interesting feature of the case is that the primary clinical presentation of the condition was a mild swelling in the attached gingiva of a mandibular molar tooth. Medical practitioners should be alert to the fact that some pathological conditions may have an initial presentation in the oral cavity. Thus, a thorough and careful examination of the oral mucosa with the accompanying dental radiographs of patients, should be noted and studied in all cases, where available.

Metastatic Ovarian Tumor of Vulvar Malignant Melanoma in a 43-Year-Old Woman: A Case Report and Literature Review

An ovarian malignant melanoma sometimes occurs from ovarian teratoma. Ovarian metastatic malignant melanoma is extremely rare. We describe a patient in whom vulvar melanoma (previously resected) metastasized to the ovary, making ovarian metastatic malignant melanoma. A 43-year-old Japanese woman was referred to us because of left ovarian tumor. She had undergone resection for malignant melanoma on the right labia minora with inguinal lymph node metastasis (pT1bN1aM0, stage IIIA, FIGO 2008). Eighteen months after this surgery, CT scans revealed left ovarian tumor and swelled pelvic lymph nodes, with a pelvic examination disclosing a left adnexal solid mass, with normal serum CA125 level (21.7 U/mL). Laparotomy revealed a left solid ovarian tumor measuring 4 cm, which was covered with a smooth grayish capsule. The right ovary, uterus, and pelvic cavity appeared normal. Upon sectioning during the surgery, the cross-sectional surface of the left ovary revealed a dark brown solid tumor. Following an intra-operative frozen-section diagnosis as metastatic melanoma, total hysterectomy with bilateral salpingo-oophorectomy and pelvic lymph dissection was performed. Histological examination confirmed the diagnosis as malignant melanoma metastasis to the left ovary and the obturator lymph node: the same laterality (left) as the primary site. The tumor was entirely composed of malignant melanoma cells with no evidence of teratoma. Combined chemotherapy with dabrafenib mesylate and trametinib was planned based on the positive BRAF mutations. This case highlights the importance that physicians should have high index of suspicion for the occurrence of ovarian melanoma metastasis after melanoma surgery. We also made extensive literature review on this issue, of which description may contribute to better understanding of this condition.

Utility of P63 in Differentiating Giant Cell Tumor from Other Giant Cell-Containing Lesions.

To assess P63 expression in giant cell-containing lesions of the bone (GCLB) and to determine its utility in differentiating giant cell tumor of the bone (GCTB) from other GCLBs. Cases diagnosed as GCLB on histopathology were included in the study. P63 immunohistochemistry was performed in all the cases. The percentage of cells showing nuclear positivity was assessed in the non-giant cell component. Statistical analysis was performed using the Mann-Whitney U test. Of the total 53 cases studied, the majority were GCTBs (23), followed by 12 cases of chondroblastomas (CBL) and 18 other giant cell lesions (GCLs). All giant cell-containing lesions except one case of CBL and brown tumor of hyperparathyroidism (BTH) showed P63 staining in the non-giant cell component. However, the mean P63 labeling of GCT (52.6%) was higher compared to CBL (28.3%), aneurysmal bone cyst (ABC) (15.2%), non-ossifying fibroma (NOF) (24.5%), giant cell lesion of small bones (GCLSB) (11%), BTH (6.8%) and chondromyxoid fibroma (CMF) (12.3%), with a p-value of < 0.001. Although p63 was present in majority of the GCLBs, its percentage positivity was significantly higher in GCTB compared to the other GCLBs. The diagnosis of GCTB is likely if cut-off value of > 50% is applied.

Oral changes in secondary to chronic kidney disease hyperparathyroidism

The most common cause of secondary hyperparathyroidism is a chronic kidney disease. The imbalance between calcium, phosphorus and vitamin D3 in the course of secondary hyperparathyroidism may affect an oral health. The changes are presented in jaw bones as a loss of bone density, focuses of demineralization or even large tumors deforming facial region – brown tumors, ossifying fibromas and aneurismal bone cysts. There is also a higher frequency of dental caries, periodontal disease and fungal infections. Secondary hyperparathyroidism in the young age may cause teeth development disorders and dental abnormalities. Dental treatment in patient with secondary hyperparathyroidism can be a challenge for a dentist, so the strict cooperation with an attending physician is needed, as well as to introduce dental prophylactic procedures as soon as possible. In addition, due to the occurrence of characteristic changes in the oral cavity, the dentist may play an important role in the primary detection of secondary hyperparathyroidism.