Osteitis fibrosa cystica (OFC) is a disorder involving the bone which is resulted from excessive production of parathyroid hormone (PTH) due to parathyroid gland hyperactivity. It was first described by Recklinghausen in 1891. Bone changes are a late presentation of hyperparathyroidism. Bone involvement in hyperparathyroidism has shown a significant decrease in incidence over the past decades (from 80% to as low as 15%). This fact might be due to the early detection of asymptomatic cases via serum calcium monitoring. PTH induces osteoclast activity which results in a bone break down. Hyperparathyroidism (PHP) might be due to parathyroid adenoma (up to 85% of cases), parathyroid hyperplasia, parathyroid carcinoma, renal osteodystrophy, and hereditary factors. Up to 5% of PHP cases develop OFC which can indicate a prolonged or more severe disease.
Osteitis fibrosa cystica presents as bone pain and characteristic radiologic findings including subperiosteal bone resorption in middle phalanges and distal radius, thinning of distal clavicle, bone cyst formation, “salt and pepper” pattern of the skull, brown tumor involving long bones and generalized osteopenia (up to 5% of cases). Brown tumors are caused by bone demineralization due to osteoclast activation, microfractures, and microhemorrhages. Its name comes from characteristic color resulting from hemosiderin deposition. OFC and its radiologic findings are more common in cases with parathyroid carcinoma compared to benign causes of PHP.
OFC results from parathyroid hormone (PTH) overproduction. PTH elevates the level of blood calcium via calcium release from the bones and calcium reabsorption in the kidney. OFC is due to increased production of PTH that can be the result of any of the following mechanisms:
Up to 85% of hyperparathyroidism cases are due to parathyroid adenomas, which are benign lesions but metabolically active.
About 5 to 10% of hyperparathyroidism cases are from hereditary factors such as multiple endocrine neoplasia (MEN) type 1 and 2A, hyperparathyroidism-jaw tumor syndrome, and familial isolated hyperparathyroidism which can result in OFC if left undiagnosed.  MEN Type 1 is the most common cause of hereditary hyperparathyroidism and is accounting for up to 95% of hereditary cases of OFC.
Parathyroid carcinoma is a rare cause of OFC in about <1% of hyperparathyroidism cases. Diagnosis of OFC onset due to carcinoma is challenging and difficult.
Renal osteodystrophy is a skeletal disorder resulting from end-stage renal disease (ESRD), which can commonly cause OFC (up to 50%). During the ESRD, kidneys are unable to make calcitriol, which promotes calcium delivery to the bones. In the shortage of calcitriol, PTH levels increase and promote calcium removal from the bones.
In the United States, osteitis fibrosa cystica is rare and occurs in less than 2% of patients with PHP and especially occurs in more severe disease and parathyroid carcinoma. Although parathyroid carcinoma is a rare cause of PHP (<1% of cases), bone involvement such as OFC occurs more frequently in parathyroid carcinoma (up to 90% of cases) compared with benign causes of hyperparathyroidism. Brown tumor has female predominance and occurs more frequently with aging (mainly after 50 years old) and post-menopause, which can be due to hormonal effects.
Osteitis fibrosa cystica is the result of the overproduction of parathyroid hormone (PTH) in the setting of primary, secondary, and tertiary hyperparathyroidism. PTH attaches to receptors on osteoblasts, which results in the expression of RANK ligand-receptor activator. RANK ligand attaches to RANK on precursors of the osteoclasts, promoting osteoclast formation. Activated osteoclasts cause bone resorption, cortical bone destruction, and fibrous cysts formation. Osteoclast-like giant cells and vascularized fibrous tissue might replace bone marrow resulting in Brown tumors, which are non-neoplastic lesions. During the Brown tumor process, bone demineralization promotes osteoclast activation. Eventually, bone resorption can cause microfractures and microhemorrhages. Overproduction of PTH can cause hyperparathyroidism via calcium release from the bone and increased reabsorption of the calcium in the kidneys.
On histopathologic examination, there is osteoclastic and osteoblastic activity with hemosiderin-laden macrophages and cyst formation.
Symptoms are due to bone softening and hypercalcemia, which might include bone mass or fractures, kidney stones, peptic ulcer, weight loss, nausea, loss of appetite, psychic moans, and abdominal groans.
Laboratory findings include elevated serum PTH, elevated serum calcium, decreased serum phosphate, and normal or elevated alkaline phosphatase. Radiographic findings may include fractures, osteopenia, osteoporosis, bowing, and bone cysts. The skull may have a ground glass appearance or salt and pepper pattern. There are no specific radiographic findings for brown tumors. CT scan, technetium scan, and ultrasound may also be helpful to detect the disorders of the parathyroid gland. It occurs mainly in the 40s and 50s and has a female predominance. Occurrence in young ages should raise the suspicion for hereditary patterns such as MEN syndrome.
Treatment of osteitis fibrosa cystica starts with the management of hyperparathyroidism, which is usually parathyroidectomy and should take place after fixing the underlying metabolic issues. After parathyroidectomy, the majority of bone disorders resulting from OFC will resolve. If surgery is not the treatment option, medical treatment may be an option to manage hypercalcemia, vitamin D deficiency, and hyperphosphatemia. Serial evaluation of serum calcium, phosphate, PTH, and vitamin D determines the necessity of treatment.
Giant cell tumor of the bone, solid aneurysmal bone cyst, and giant cell reparative granuloma are included in the differential diagnoses for Brown tumors. OFC is a reactive and non-neoplastic lesion but sometimes may be misdiagnosed as a malignant lesion and can show histopathologic features of giant cell tumor of the bone. It can also be mistaken for a metastatic disease based on the radiologic findings, such as multiple scattered osteolytic lesions.
The bone issues resulting from OFC are usually resolved after parathyroidectomy. Proper management of hyperparathyroidism results in decreased osteoclastic activity, and new bone deposition.
Osteitis fibrosa cystica might cause pain and fracture in legs, arms, spine, or any other part of the skeletal system. Hyperparathyroidism may cause renal failure and kidney stones.
In the United States, osteitis fibrosa cystica is rare and occurs in less than 2% of patients with PHP and mainly occurs in more severe disease. Hypercalcemia is usually detected as an incidental finding during routine medical check-up before any severe damage occurs.
Early diagnosis and management of hyperparathyroidism might limit the amount of damage from OFC. An annual medical check-up, including testing for serum calcium and phosphorus, can aid in early detection of asymptomatic hyperparathyroidism and limit its bone complications. An interprofessional team approach to the evaluation and treatment of hyperparathyroidism will provide the best outcome.
|||Kalapala L,Keerthi Sai S,Babburi S,Venigalla A,Pinisetti S,Kotti AB,Ganipineni K, An Endocrine Jaw Lesion: Dentist Perspective in Diagnosis. Case reports in dentistry. 2016; [PubMed PMID: 27974979]|
|||Kearns AE,Thompson GB, Medical and surgical management of hyperparathyroidism. Mayo Clinic proceedings. 2002 Jan; [PubMed PMID: 11794462]|
|||Shane E,Bilezikian JP, Parathyroid carcinoma: a review of 62 patients. Endocrine reviews. 1982 Spring; [PubMed PMID: 7044770]|
|||Silverberg SJ,Shane E,de la Cruz L,Dempster DW,Feldman F,Seldin D,Jacobs TP,Siris ES,Cafferty M,Parisien MV, Skeletal disease in primary hyperparathyroidism. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research. 1989 Jun; [PubMed PMID: 2763869]|
|||Eubanks PJ,Stabile BE, Osteitis fibrosa cystica with renal parathyroid hormone resistance: a review of pseudohypoparathyroidism with insight into calcium homeostasis. Archives of surgery (Chicago, Ill. : 1960). 1998 Jun; [PubMed PMID: 9637471]|
|||Guru SC,Goldsmith PK,Burns AL,Marx SJ,Spiegel AM,Collins FS,Chandrasekharappa SC, Menin, the product of the MEN1 gene, is a nuclear protein. Proceedings of the National Academy of Sciences of the United States of America. 1998 Feb 17; [PubMed PMID: 9465067]|
|||Carling T, Molecular pathology of parathyroid tumors. Trends in endocrinology and metabolism: TEM. 2001 Mar; [PubMed PMID: 11167122]|
|||Moe S,Drüeke T,Cunningham J,Goodman W,Martin K,Olgaard K,Ott S,Sprague S,Lameire N,Eknoyan G, Definition, evaluation, and classification of renal osteodystrophy: a position statement from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney international. 2006 Jun; [PubMed PMID: 16641930]|
|||Shane E, Clinical review 122: Parathyroid carcinoma. The Journal of clinical endocrinology and metabolism. 2001 Feb; [PubMed PMID: 11157996]|
|||Givi B,Shah JP, Parathyroid carcinoma. Clinical oncology (Royal College of Radiologists (Great Britain)). 2010 Aug; [PubMed PMID: 20510594]|
|||Glushko T,Banjar SS,Nahal A,Colmegna I, Brown tumor of the pelvis. Cleveland Clinic journal of medicine. 2015 Dec; [PubMed PMID: 26651887]|
|||Parisien M,Silverberg SJ,Shane E,Dempster DW,Bilezikian JP, Bone disease in primary hyperparathyroidism. Endocrinology and metabolism clinics of North America. 1990 Mar; [PubMed PMID: 2192867]|
|||Marx SJ, Hyperparathyroid genes: sequences reveal answers and questions. Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists. 2011 Jul-Aug; [PubMed PMID: 21454225]|
|||Ganesan J,Spanier S,Bridge JA, Cytogenetic findings in a case of brown tumor associated with hyperparathyroidism. Cancer genetics and cytogenetics. 2000 Jun; [PubMed PMID: 10905852]|
|||TENG CT,NATHAN MH, Primary hyperparathyroidism. The American journal of roentgenology, radium therapy, and nuclear medicine. 1960 Apr; [PubMed PMID: 13837411]|