How should a Brown's tumor be managed?

Management of Brown Tumor

Brown tumors should be managed primarily by treating the underlying hyperparathyroidism through parathyroidectomy for primary hyperparathyroidism or medical management for secondary hyperparathyroidism, with surgical intervention reserved only for lesions causing pathological fractures, severe pain unresponsive to medical management, or critical structural instability. 1, 2, 3

Initial Diagnostic Workup

The diagnostic approach must establish the underlying hyperparathyroid etiology before any intervention:

• Measure serum calcium and parathyroid hormone (PTH) levels to confirm hyperparathyroidism as the cause of the bone lesion 1
• Obtain cross-sectional imaging (CT or MRI) to assess the extent of disease and identify additional lesions throughout the skeleton 1, 3
• Consider biopsy only when diagnosis remains uncertain, as brown tumors are frequently misdiagnosed as malignancy, but tissue confirmation may be necessary to avoid inappropriate oncologic treatment 1, 4

Critical Diagnostic Pitfall

Brown tumors must be distinguished from ossifying fibromas of the jaw seen in CDC73-related Hyperparathyroid-Jaw Tumor Syndrome, which are distinct pathologic entities 1. Additionally, the histologic appearance with multinucleated giant cells can mimic giant cell tumor or even metastatic disease, leading to devastating misdiagnosis and unnecessary chemotherapy or radiotherapy 4, 5.

Primary Treatment Strategy

For Primary Hyperparathyroidism

Parathyroidectomy is the definitive treatment and should be performed as soon as the diagnosis is established 1, 3, 5:

• Surgical removal of the parathyroid adenoma addresses the root cause of excessive PTH-driven osteoclast activation 1
• Most brown tumors regress spontaneously after successful parathyroidectomy without requiring direct surgical intervention 3, 6
• Biochemical parameters typically normalize within 3 months postoperatively 4
• Monitor for hungry bone syndrome postoperatively, which may require aggressive calcium and vitamin D supplementation 5

For Secondary Hyperparathyroidism (Renal Disease)

Medical management is the first-line approach 1, 5:

• Vitamin D analogs and phosphate binders are used to control PTH levels 1
• Parathyroidectomy is reserved for medically refractory cases with severe, uncontrolled hyperparathyroidism despite optimal medical therapy 1, 5
• Total parathyroidectomy can result in significant tumor regression even in advanced cases 6

Indications for Orthopedic Surgery

Surgical intervention on the brown tumor itself should be considered only in specific clinical scenarios 2, 3:

Absolute Indications

• Pathological fractures requiring stabilization 2, 3
• Impending fractures in weight-bearing bones with large defects and high fracture risk 2, 3
• Acute radicular symptoms from spinal lesions causing nerve compression 2
• Severe, localized pain unresponsive to treatment of the underlying hyperparathyroidism 2, 3

Surgical Techniques When Intervention is Required

When orthopedic surgery is necessary, the following approaches have proven effective 2, 3:

• Intralesional curettage is the most common procedure (performed in 82.6% of surgical cases) 3
• Bone cement (polymethylmethacrylate) filling of the resulting cavity provides immediate structural support and pain relief 2, 3
• Bone grafting is an alternative to cement for cavity filling 3
• Less invasive stabilization systems with internal fixation decrease fracture risk while minimizing surgical morbidity 2
• Laminectomy with internal fixation for spinal lesions causing neurologic compromise 2

Conservative Management Approach

The majority of brown tumor lesions (64.6% in one series) can be managed conservatively after addressing the underlying hyperparathyroidism 3:

• Close monitoring with serial imaging to document regression 3, 6
• Endocrinology consultation to optimize calcium and PTH control 2, 5
• Radiography is required only if focal bone pain, pathological fractures, or radicular symptoms develop 2
• Significant regression typically occurs within months of successful parathyroid treatment 6

Multidisciplinary Coordination

Treatment requires coordination between endocrinology, general surgery, and orthopedic surgery 3, 5:

• Endocrinology consultation before any surgical intervention is essential 3
• General surgery performs the parathyroidectomy 3, 5
• Orthopedic surgery addresses skeletal complications when conservative management fails 2, 3

Key Clinical Pitfalls to Avoid

• Do not perform aggressive surgical resection of brown tumors before treating the underlying hyperparathyroidism, as most lesions will regress with metabolic correction alone 3, 6
• Do not misinterpret brown tumors as primary bone malignancy or metastatic disease, which can lead to inappropriate chemotherapy or radiotherapy 4, 5
• Do not delay parathyroidectomy in primary hyperparathyroidism, as prolonged PTH elevation causes progressive skeletal destruction 1, 5
• Do not overlook the possibility of hungry bone syndrome after parathyroidectomy in patients with severe, long-standing disease 5

Prognosis

No recurrence of brown tumors occurs after successful treatment of hyperparathyroidism 3. The lesions represent a reversible complication of PTH excess rather than a neoplastic process, and they resolve once the metabolic derangement is corrected 1, 6.