Presentation of case
A 56-year-old West African male patient was admitted into an acute medical hospital following a hypertensive crisis. A Computed Tomography (CT) scan of the head and body was conducted, with a report highlighting a thickened aorta and small bilateral kidneys. This prompted a Fluoro-Deoxy-Glucose Positron Emission Tomography (FDG PET) scan to exclude vasculitis as the cause. No evidence of vasculitis was present. An incidental finding was focal metabolic activity in the right lobe of the thyroid gland (Fig 1). An FDG PET avidnodule in the thyroid gland is an indication for malignancy in 30%of cases(5).Further investigation in the form of an ultrasound and fine needle aspiration cytology (FNAC)was arranged to exclude a thyroid malignancy.
The ultrasound scan showed a suspicious nodule in the right lobe of the thyroid. It also showed an extra-thyroid nodule at the deepsurface of the gland (Fig 2). This extra-thyroid nodule was suspicious for a parathyroid adenoma, but the possibility of lymph node metastasis was also considered. A Fine Needle Aspiration was conducted of both nodules providing a coupled diagnosis of a papillary thyroid carcinoma and parathyroid adenoma. Further imaging in the form of a SestamibiSingle Photon Emission Computed Tomography (SPECT CT) scan supported this diagnosis (Fig 3) and excluded the possibility of any ectopically positioned parathyroid tissue in the neck or mediastinum.The patient was scheduled for total thyroidectomy and surgical removal of the parathyroid adenoma.
Prior to undergoing surgery, the patient presented as an outpatient to a dental hospital with the principle complaint of multiple intraoral swellings. These swellings were of fleshy consistency with an exophytic growth-like appearance. There was no evidence of discharge present (figures 4 and 5). Apanoramic radiograph was obtained (figure 6) showing two radiolucencies in the bone, a retained root in the right maxilla, periodontal bone loss and a dense bone island in the right mandible. The two radiolucencies had well-defined but non-corticatedmargins. They had the appearance of ‘scooped out’ defects. The bony defect in the lower left second molar region caused the tooth to have a ‘floating appearance’ with loss of virtually all bony support. Previous imaging was reviewed, the FDG PET CTshowed areas of focal uptake at sites corresponding to those seen on the panoramic radiograph. The CT component showed a soft tissue mass in the right maxilla and bony expansion in the left mandible, with intact corticated margins (Fig 7). As this patient had a known diagnosis of papillary thyroid carcinoma jaw metastasis was considered. However, the well-defined outline and lack of aggressive, permeative features suggested a benign pathology was more likely. Browns tumours seemed most likely given that there was also a known diagnosis of hyperparathyroidism.
Biopsy was arranged to allow for a definitive diagnosis.A local anaesthetic excisional biopsy of the upper right quadrant was obtained at the dental hospital.A bosselated, rubbery tumour-like mass was excised (Fig 8). A histology report followed describing “mononuclear cells with vesicular nuclei/small nucleoli, which are mixed with erythrocytes and singly arranged osteoclast-like multinuclear giant cells.” The features were consistent with a “Brown Tumour of hyperparathyroidism”. A decision was made to monitor the radiolucent lesion in the lower left quadrant.
As planned the patient had a total thyroidectomy as surgical management for the papillary thyroid carcinoma and adjuvant radio-iodine ablation was also prescribed.The parathyroid adenoma was also surgically removed in order to manage the hyperparathyroidism. Following the correction of the hyperparathyroidism, the patient was reviewed in the dental hospital. A further panoramic radiograph (figure 9) was obtained showing complete healing in the lower left quadrant at the site of previous radiolucency. The area had filled in with bone, with a somewhat sclerotic appearance. This was of stark contrast to the previous panoramic radiographobtained 1 year earlier when there wascomplete vertical bone loss at the distal aspect of the lower left second molar. There was also evidence of bony infill at the right maxillary site.
No further dental surgical intervention was necessary. The patient did exhibit periodontal disease and his general dental practitioner was contacted to address this issue. The patient was kept on review at the dental hospital. Appearances remained stable at two years follow up.