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LETTERS TO THE EDITOR
Year : 2018  |  Volume : 22  |  Issue : 2  |  Page : 291-292

Multiple lytic lesions on F-18 fluorodeoxyglucose positron emission tomography/computed tomography not always metastatic?


Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication14-May-2018

Correspondence Address:
Nishikant Avinash Damle
Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijem.IJEM_32_18

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How to cite this article:
Passah A, Arora S, Damle NA. Multiple lytic lesions on F-18 fluorodeoxyglucose positron emission tomography/computed tomography not always metastatic?. Indian J Endocr Metab 2018;22:291-2

How to cite this URL:
Passah A, Arora S, Damle NA. Multiple lytic lesions on F-18 fluorodeoxyglucose positron emission tomography/computed tomography not always metastatic?. Indian J Endocr Metab [serial online] 2018 [cited 2018 May 20];22:291-2. Available from: http://www.ijem.in/text.asp?2018/22/2/291/232372



Sir,

A 26-year-old female presented with complaints of pain in the left knee since 2 years and right arm pain and swelling for 2 weeks. The patient had a history of fall 2 months ago. Radiographs of the arm and thigh revealed lytic lesions in mid shaft of right humerus associated with pathological fracture and lytic lesion in the left femoral shaft. The patient was referred for an F-18 fluorodeoxyglucose positron emission tomography/computed tomography scan (F-18 FDG PET/CT) which revealed lytic lesions with variable FDG uptake involving extensive skeletal sites associated with pathological fractures [Figure 1]. Generalized osteopenia was also noted. In addition to this, a well-defined soft tissue density nodule measuring 2.1 cm × 1.6 cm was seen posterior to lower pole of left thyroid lobe which showed low FDG uptake [Figure 1]b and [Figure 1]c. Based on the above findings, serum calcium and serum parathyroid hormone (PTH) levels were sought. Due to elevated serum calcium, serum PTH levels, multiple lytic lesions with pathological fractures and diffuse osteopenia, a clinical suspicion of parathyroid adenoma arose. Subsequently, the patient underwent Technetium 99 m sestamibi scan (Tc99m MIBI) which revealed a left-sided parathyroid adenoma [Figure 2]. Although F18 FDG PET/CT is routinely used for investigating multiple lytic lesions, this is an important example of how a biochemical screening could have changed the diagnostic algorithm. A simple endocrine evaluation thus eventually resulted in guiding a definitive surgical cure for the patient. This patient underwent surgery and histopathology confirmed a parathyroid adenoma.
Figure 1: F-18 fluorodeoxyglucose positron emission tomography/computed tomography maximum intensity projection image (a) and fused positron emission tomography/computed tomography and computed tomography images at neck (b and c) soft-tissue density nodule posterior to left lobe of thyroid with no significant fluorodeoxyglucose uptake (thick white arrow) and multiple lytic lesions as shown in fused positron emission tomography/computed tomography axial sections at pelvis (d) with no significant uptake (small white arrow) and at knee level (e) with increased fluorodeoxyglucose uptake (white arrow)

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Figure 2: Tc99m MIBI early image (a) radiotracer uptake in both lobes of thyroid gland with delayed image, curved arrow (b) wash-out of tracer from thyroid and persistent uptake which corresponds to soft tissue density nodule posterior to lower pole of thyroid in single-photon emission computed tomography/computed tomography image (white arrow) (c and d)

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Primary hyperparathyroidism characterized by elevated serum PTH due to hyperfunctioning parathyroid glands manifests as hypercalcemia due to abnormal bone metabolism and brown tumors.[1],[2] Brown tumors are non-neoplastic and are due to high osteoclastic activity leading to bone resorption.[1] The sensitivities of Tc99 m MIBI scintigraphy, ultrasound, and combined techniques have been reported to be about 85.3%, 72.5%, and 90.4%, respectively.[3] Parathyroid surgery is the only definitive cure for primary and tertiary hyperparathyroidism.[4] Cases has been reported in which patients diagnosed with brown tumors have resolved after successful parathyroidectomy due to mineralization of the brown tumors after normalization of the serum calcium and PTH levels.[5] This case demonstrates how biochemical evaluation of calcium, phosphorus, and PTH changed the whole management in the light of F-18 FDG PET/CT findings.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
H1Selvi F, Cakarer S, Tanakol R, Guler SD, Keskin C. Brown tumour of the maxilla and mandible: A rare complication of tertiary hyperparathyroidism. Dentomaxillofac Radiol 2009;38:53-8.  Back to cited text no. 1
    
2.
Sun C, Xu X, Wang X, Sheng W, Wen S, Han J, et al. Thymic carcinoma with tumor thrombus protruding into the superior vena cava and the right atrium. Thorac Cancer 2013;4:333-4.  Back to cited text no. 2
    
3.
Ozkaya M, Elboga U, Sahin E, Kalender E, Korkmaz H, Demir HD, et al. Evaluation of conventional imaging techniques on preoperative localization in primary hyperparathyroidism. Bosn J Basic Med Sci 2015;15:61-6.  Back to cited text no. 3
    
4.
Sethi N, England RJA. Parathyroid surgery: From inception to the modern day. Br J Hosp Med (Lond) 2017;78:333-7.  Back to cited text no. 4
    
5.
Brabyn P, Capote A, Belloti M, Zylberberg I. Hyperparathyroidism diagnosed due to brown tumors of the jaw: A Case report and literature review. J Oral Maxillofac Surg 2017;75:2162-9.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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