Fig. 1Mongolian magnetic resonance imaging of the affected shoulder (A, T1 coronal; B, T2 coronal FS; C, T2 sagittal view) showed 5 cm-sized expansile tumorous lesion with heterogeneous signal intensity on right humerus metaphysis, with internal cystic change containing fluid level inside.
Fig. 2Plain digital radiograph of the affected left wrist and hand (A), humerus (B), both tibia (C, left tibia; D, right tibia) and foot (E, left foot; F, right foot) revealed multiple bony osteolytic expansile lesions (arrows) with cortical thinning, diffuse osteoporosis and subperiosteal bone resorption, without definite evidence of pathological fractures in both tibia and fibula, metatarsal bones, left proximal ulna and humerus, left distal ulnar and 3rd metacarpal bone. These findings are thought to compatible with brown tumors of hyperparathyroidism and not like malignancy.
Fig. 3Skull X-ray showed a granular "salt and pepper" appearance, which is thought to be a typical finding of primary hyperparathyroidism. It also showed enlargement of the sella turcica, which can be commonly seen in cases of pituitary tumors.
Fig. 4Ultrasound of neck revealed several nodules which were thought to be parathyroid; well-defined hypoechoic nodules sized 0.85 cm, 0.75×0.74 cm, maximum size is 1.83 cm, and there was no other significant lymphadenopathy
Fig. 5 To further assess the parathyroid gland, technetium-99m (Tc-99m) sestamibi parathyroid scan was carried out, showing normal uptake pattern in both Tc-99m peretechnetate and focally increased residual uptake at the lower pole region of left thyroid lobe in the Tl-Tc pertechnetate subtraction image (A, early phase; B, delayed phase). This result showed "parathyroid adenoma" close to the left lower pole of left thyroid.
Fig. 6Histopathological report showed features of parathyroid adenoma as above (H&E stain, A,×100; B, ×200). In figure (A) and (B), within the adenoma, tumor cells are arranged in cords and solid sheets. The tumor cells are mainly composed of chief cells, which have centrally placed hyperchromatic nuclei and pale eosinophilic cytoplasm.