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.