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On her 1st admission (July, 1989), findings showed following: (1) serial serum calcium determination was
3 cm. fixed, hard and nontender mass on the left persistently elevated (3.27, 3.06, 3.12); (2) serum
maxillary area. Excision biopsy via Caldwell-Luc phosphate waslow at0.761 mmolXl (normal value=0.8-
approach was done and histopathologic diagnosis was 1.6 mmolXl); (3) skeletal survey revealed a general-
Giant Cell Granuloma. She was discharged asymp- ized skeletal demineralization, granular localization
tomatic only to be readmitted 2 months later because (salt and pepper appearance) of the skull and nephof
a recurrent progressive growth over the same site. roclacinosis with the renal calculus (see Figure 1);
(4) ultrasonography of the neck revealed a 1.7 x 1.2
On her second admission (Sept., 1989), the patient x 0.9 era. hypoechoic mass in the inferior portion of
presented a slightly firm, non tender 7 x 4 cm. left the right thyroid probably an enlarged parathyroid,
maxillary mass which was encroaching on the leR thyroid gland essentially normal. All the other laboorbit
causing diplopia on downward gaze. The left ratory examinations (FBS, BUNXCrea, Na, K, CI, urine
gingivobuccal gutter was obliterated anteriorly. No calcium, creatine clearance) were normal.
paresthesia were noted. Routine laboratory examinations
(urinalysis, CBC, BUNXCreatinine, serum Na, The patient underwent neck exploration flow-collar
K, CI, Chest PA) for pre-operative clearance were incision) which revealed a 2 x 1.5 x 1 cm. firm solid
unremarkable..Waters and Basal views revealed an mass under the right inferior thyroid vessels. The mass
expansile soft tissue opacity in the left maxillary area was removed and frozen section was read as Paraextending
upward to the inferior aspect of the orbit thyroid Adenoma. The right superior parathyroid and
laterally, mucoperiosteal thickening was noted in the the two left parathyroid glands were explored and
right maxillary sinus, the inferior rim of the orbit and identified and were found to be normal in size and
anterior aspect of the left zygomatic bone were not appearance. The maxillary mass was left untouched.
delineated. She underwent a second operation (Weber-
Ferguson incision with lip splitting) with the follow- The patient tolerated the procedure very well. The
ing findings: the mass eroded the anterior and lateral post operative serum calcium level was low at 1.97
maxillary walls, filled the maxillary antrum and mmolM, She manifested symptoms of hypocalcemia
partially eroded the orbital floor. Frozen section of which was readily controlled with calcium supplethe
mass was read as Giant Cell Tumor. The bed was ments. The final histopathology report was read as:
then extensively cleaned of tumor. The patients post- Parathyroid tissue, in the absence of capsule in the
operative course was uneventful. She was discharged section submitted, distinction between Parathyroid
after 9 days. The final histopathologic report was Giant Adenoma and Hyperplasia must be clinically corre-
Cell Tumor.
lated. (See Figure 2). Review of slides of 2 previous
operations was read as consistent with Brown Tumor
Two months later, .the patient again noted swel- of Hyperparathyroidism. (See Figure 3).
ling of the left maxillary area lateral to the previous
site. By this time, she was lost to follow-up only to The patient was eventually discharged and subcome
back with markedly enlarged maxillary mass. sequent follow-ups revealed a progressive decrease
Differential diagnosis for Giant Cell Tumor were con- in the size of the maxillary mass with resolution of
sidered. Subsequent work- ups revealed serum cal- diplopia. (See Figure 4).
cium to be abnormally high at 3.27 mmolXl (normal
value----=2.35-2.75 mmolM). She was then referred to
the Endocrine section for parathyroid hormone level DISCUSSION
which likewise turned out to be markedly elevated
at 47.69 mg'_ml (normal value=0.4-1.4 tug'real). She Hyperparathyroidism is a disorder of the paratywas
eventually admitted for the third time. roid glands characterized by the abnormal secretion
of parathyroid hormone leading to hypercalcema. The
On her present admission (April, 1989), physical incidence of primary hyperparathyroidism has been
examination showed a 7 x 8 cm. firm, slightly tender, reported between 25 and 50 per 100,000 population
ill-defined mass extending from left molar to the left per year. The highest incidence occurs in women in
zygomatic area with persistence of diplopia on the fourth to sixth decade of life approaching 200
downward gaze. The rest of the examination was cases per 100,000 population per year.
essentially normal. Diagnostic studies showed the
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