Case report
Unusually rapid growth of brown tumour in the mandible after parathyroidectomy associated with the presence of a supernumerary parathyroid gland

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Abstract

The aim of this study is to report the case of a quick growing brown tumour in the jaw after a parathyroidectomy due to the presence of a rare fifth parathyroid gland. The patient had chronic renal disease and the diagnosis was tertiary hyperparathyroidism. Thirty days after the parathyroidectomy, the patient returned with a significant increase in the tumour size. The suspicion of a supernumerary gland was confirmed by parathyroid scintigraphy. The treatment of brown tumour is dependent on the treatment of the hyperparathyroidism. However, curettage should be considered if a large lesion is disturbing mastication. In conclusion, this case should attract the attention of general practitioner dentists, since they may be the first professionals who have contact with the patient with a brown tumour in the jaws. Likewise, this case emphasises the importance of knowing the type of hyperparathyroidism involved to allow for effective treatment planning.

Introduction

The brown tumour is an unusual giant cell tumour of the maxillofacial skeleton that appears as late bony manifestations of severe hyperparathyroidism (HPT), as a consequence of undiagnosed or untreated HPT where the bone metabolism is abnormal (Smith and Ward, 1978). The increased circulating levels of parathyroid hormone increase osteoclastic bone resorption, primarily in cortical bone (Triantafillidou et al., 2006).

The HTP may be classified into three categories: primary, secondary and tertiary. Primary hyperparathyroidism is not a rare disease and the primary form is due to excessive production of parathyroid hormone (PTH) secretion by an autonomous gland resulting in hypercalcaemia. Secondary hyperparathyroidism as a result of hypocalcaemia, vitamin D deficiency or chronic renal insufficiency, which acts as a stimulus for PTH production. Tertiary HPT, first described in 1963, is the rarest form of hyperparathyroidism, affecting patients with long-standing secondary HPT who, in the setting of renal failure, develop hypersecretion of PTH (Davies et al., 1968).

Histologically there is no difference between a brown tumour and central giant cell granuloma (CGCG). Thus, the diagnosis of brown tumour can be made through the use of biochemical tests such as serum calcium, alkaline phosphatase, phosphorus, sodium, potassium and intact PTH levels, and also through the findings of PTH (Pinto et al., 2006).

Its treatment is initially based on treating the underlying endocrine abnormality. Surgical excision of the diseased parathyroid gland to control PTH is the first choice of treatment for a brown tumour because the normalisation of parathyroid function should lead to a reduction in size or disappearance of the tumour (Pinto et al., 2006). However, brown tumour management depends on the severity of the lesions present.

The aim of this paper is to report a rare case of a rapidly growing brown tumour in the jaw associated with tertiary hyperparathyroidism and present the importance of a thorough early diagnosis for successful treatment. This should allow a dentist to understand the disease and to refer the patient for the correct treatment.

Section snippets

Report of a case

A 21-year-old male patient was referred to the Department of Diagnosis and Surgery at São Paulo State University in May 2007 for the evaluation of asymptomatic facial asymmetry which was noticed 30 days previously. Swelling of the posterior region of the right side of the mandible was evident (Fig. 1a). Medical history was significant, with chronic renal insufficiency and anaemia. The patient had been undergoing dialysis three times a week which he began two years before the clinical onset of

Discussion

The diagnosis of a brown tumour is the result of the sum of the medical history of patients with clinical, radiographic, laboratory findings and pathological examinations (Selvi et al., 2009). Although the histology of the brown tumour and CGCG has the same characteristics, the cause of development of both lesions is different. CGCG is a proliferative process that most often affects young adults and children and can be detected unexpectedly on routine radiographic films or present as a slowly

Conclusion

This case should attract the attention of general practitioner dentists, as a brown tumour may manifest itself in the jaws and dentists may be the first professionals to be consulted by the patient.

The clinical and radiographic signs in the jaws should also alert dentists for the possible presence of brown tumours in patients who have previously been diagnosed with hyperparathyroidism.

This case also highlights the importance of early diagnosis of a brown tumour and knowledge of the forms of

Acknowledgements

The authors acknowledge with sincere thanks to Mrs. Kim Kubitza for correcting the English language in this article.

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