Radiologic Investigations

Patients with classic osteitis fibrosa cystica have subperiosteal bone resorption best observed on the radial aspect of the middle and distal phalanges on hand radiographs. Other skeletal manifestations of severe primary hyperparathyroidism include bone cysts, osteoclastomas or "brown tumors," pathologic fractures, and general demineralization. The skull may exhibit a finely mottled, ground-glass appearance, with loss of definition of the inner and outer cortices.38 Abdominal flat plates or ultrasonography may reveal renal stones.

Bone densitometry studies are currently being performed more frequently and may be utilized in assessing the effects of primary hyperparathyroidism on bone. Primary hyperparathyroidism mainly leads to loss of bone at cortical sites such as the distal radius. Bone density is relatively preserved at sites such as the lumbar spine, which is rich in cancellous bone.39 This is in contrast to the bone density changes seen in menopause. In the latter, the lumbar spine is the major target of bone mineral loss. Despite these findings, lumbar spine density improves after parathyroidectomy.40,41

Localizing tests such as ultrasonography, sestamibi scanning, magnetic resonance imaging, or computed tomography scanning are used by some clinicians to make or confirm the diagnosis of primary hyperparathyroidism. One should emphasize, however, that the diagnosis of primary hyperparathyroidism is made by metabolic testing; localization tests often identify the tumor site but do not make the diagnosis, because both false-positive and false-negative localization tests occur.42

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