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Saudi Journal of Kidney Diseases and Transplantation
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LETTER TO THE EDITOR  
Year : 2016  |  Volume : 27  |  Issue : 4  |  Page : 821-822
Remarks about the study on mandibular mass in a child on hemodialysis


Department of Pediatrics, Al-Kindy College of Medicine, Baghdad University, Baghdad, Iraq

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Date of Web Publication5-Jul-2016
 

How to cite this article:
Al-Mendalawi MD. Remarks about the study on mandibular mass in a child on hemodialysis. Saudi J Kidney Dis Transpl 2016;27:821-2

How to cite this URL:
Al-Mendalawi MD. Remarks about the study on mandibular mass in a child on hemodialysis. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2021 Oct 18];27:821-2. Available from: https://www.sjkdt.org/text.asp?2016/27/4/821/185280
To the Editor ,

With reference to the interesting case report by Youssef et al, [1] there are two aspects that are worth commenting upon.

First, the authors made the presumptive diagnosis of brown tumor (BT) in the studied child with a mandibular mass based on the results of laboratory tests [high intact parathormone (PTH) of 602 pg/mL, serum calcium of 9.7 mg/dL, phosphorus of 5 mg/dL, and Vitamin D level of 13 ng/mL] and the multi-slice computed tomography scan findings (unilocular, expansile, osteolytic lesion in the mandibular body at its left paramedian aspect, homogeneous attenuation, and loss of the bony trabeculae with rarified related alveolar margin, resorption of the outer cortical margin and associated soft tissue component). [1] Accordingly, the authors attempted a trial of intensive course of intravenous active Vitamin D for three months. Since the mass did not show any signs of regression, and in view of the disfiguring picture and possibility of a behavior mimicking a malignant lesion, surgical treatment was performed with curettage of the affected bone lesion and the mass was excised. Biopsy of the lesion demonstrated a central giant cell lesion between other giant cells that were sheets of plump fibroblasts with a rich vascular network, highly suggestive of a BT. [1] It believe that the employed diagnostic protocol has resulted in delaying the definitive diagnosis of BT, and hence, deterring implementing effective therapy. It is obvious that renal osteodystrophy (ROD), encompassing different osseous lesions, is associated with different pathogenetic mechanisms, including disorder of calcium-phosphate metabolism, impaired metabolism of Vitamin D, and increased parathyroid activity that lead to high concentrations of PTH. [2] However, histomorphometric findings in chronic hemodialysis patients have revealed that there is a wide spectrum of ROD and a shift toward the value of PTH is limited to low turnover disease and high-turnover osteodystrophy might present with low PTH levels. [3] Bone biopsy remains the "gold standard" diagnostic tool for various osseous lesions in ROD, including BT. [3] I wonder why the authors did not attempt initially to perform a biopsy from the mandibular mass to hasten early diagnosis.

Second, the authors addressed that surgical excision of the mandibular mass was contemplated. [1] However, a regular follow-up of the case in question was not scheduled. Recurrence of BT is not uncommon in patients with hyperparathyroidism (HPT). [4] It was expected that the studied hemodialysis patient with secondary HPT could have a recurrence of BT. Therefore, the authors should have considered parathyroidectomy since it has been found that such modality of therapy could stop maladaptive PTH stimulation, which leads not only to the formation of osteoblastic progenitors that become fibroblast-like cells but also to osteoclast formation. [5] Moreover, it facilitates the long-term control of HPT and calcium-phosphate metabolism in children with chronic kidney diseases and might thus mitigate uremic bone and cardiovascular disease. [6]

 
   References Top

1.
Youssef DM, Mohammed FF, Adham T. Mandibular mass in a child on hemodialysis. Saudi J Kidney Dis Transpl 2016;27:144-6.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.
Pechalova PF, Poriazova EG. Brown tumor at the jaw in patients with secondary hyperparathyroidism due to chronic renal failure. Acta Medica (Hradec Kralove) 2013;56:83-6.  Back to cited text no. 2
[PUBMED]    
3.
Gal-Moscovici A, Popovtzer MM. New worldwide trends in presentation of renal osteodystrophy and its relationship to parathyroid hormone levels. Clin Nephrol 2005;63:284-9.  Back to cited text no. 3
[PUBMED]    
4.
Morano S, Cipriani R, Gabriele A, Medici F, Pantellini F. Recurrent brown tumors as initial manifestation of primary hyperparathyroidism. An unusual presentation. Minerva Med 2000;91:117-22.  Back to cited text no. 4
[PUBMED]    
5.
Hata T, Irei I, Tanaka K, Nagatsuka H, Hosoda M. Macrognathia secondary to dialysis-related renal osteodystrophy treated successfully by parathyroidectomy. Int J Oral Maxillofac Surg 2006;35:378-82.  Back to cited text no. 5
[PUBMED]    
6.
Schaefer B, Schlosser K, Wühl E, et al. Longterm control of parathyroid hormone and calcium-phosphate metabolism after parathyroidectomy in children with chronic kidney disease. Nephrol Dial Transplant 2010;25:2590-5.  Back to cited text no. 6
    

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Correspondence Address:
Prof. Mahmood Dhahir Al-Mendalawi
Department of Pediatrics, Al-Kindy College of Medicine, Baghdad University, Baghdad
Iraq
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DOI: 10.4103/1319-2442.185280

PMID: 27424707

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