Brown tumors compressing the spinal cord

Case contributed by Dr Yair Glick

Presentation

Right abdominal pain in end-stage renal disease (ESRD) patient on dialysis with tertiary hyperparathyroidism.

Patient Data

Age: 25 years
Gender: Male

Normal bowel gas distribution.
Cluster of fine small curvilinear calcifications projected onto left lower abdomen/left iliac wing.
Lytic lesions in the right 11th rib, right acetabulum, superior pubic rami, and left ischium.
Lumbar scoliosis, convex to the left.

CT

CT chest-abdomen

The chest was scanned without contrast material injection due to a technical fault.

Numerous soft tissue density lytic lesions in most of the imaged bones, some expansile (e.g. posterior arch of the right 9th rib, left ischium). Lesion in T9 posterior arch protruding forward into the spinal canal and severely compressing the thecal sac.

Enlarged cardiac chambers.
Bovine arch - common anatomical variant.
Posterior pleural thickening on right.

Severely atrophied kidneys with extrarenal pelvises, dilated right ureter.
Ovoid structure with small internal linear/stippled calcifications, immediately lateral to the left psoas major muscle, approximately the same diameter as the muscle - non-functioning transplanted kidney.

Bone window: diffuse osteosclerosis.

In light of the patient's ESRD and hyperparathyroidism, the skeletal findings strongly favor renal osteodystrophy (ROD) with brown tumors.

MRI

MR cervico-thoraco-lumbar spine

Numerous lytic lesions throughout the bony skeleton, exhibiting a mildly high signal on both T1WI and T2WI, some with small cystic components. 

Posterior cortical breach with spinal canal compression at heights
T6: mild left compression
T8: mild anterior compression
T9: significant posterior compression with cord compression
L1: mild posterior compression

Case Discussion

Patient with end-stage renal disease due to dysplastic kidneys, renal osteodystrophy and tertiary hyperparathyroidism presented to the ER with acute-onset right abdominal pain. Lab tests were unremarkable. CT showed many lytic lesions consistent with brown tumors, several of which compressed the spinal cord, most severely especially at the T9 level.

Tumor markers were all negative. Pathology report of a vertebral biopsy came back as "compatible with brown tumor".

Neurological exam was partly abnormal, with a positive Babinsky test.

The patient underwent spinal decompression and fixation and subtotal parathyroidectomy (3 out of 4 glands).

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Case information

rID: 68442
Published: 3rd Jun 2019
Last edited: 14th Aug 2019
Inclusion in quiz mode: Included
Institution: Laniado Hospital

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